Catarina Bastião de Almeida1, Beatriz Andrade2, Cristel Gonçalves1, Sofia Costa Lima1.
1Pediatrics Department, Unidade Local de Saúde Loures Odivelas, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal,
2Pediatrics Department, Unidade Local de Saúde Santa Maria, Hospital Santa Maria, Lisbon, Portugal.
ADDRESS FOR CORRESPONDENCE
Ana Catarina Duarte Sequeira Bastião de Almeida, Rua José Estêvão, 83E, 4º direito; 1150-200 Lisboa, Portugal.
Email: catarina.balmeida@hotmail.com | | Keywords | | Mycoplasma pneumoniae, Reactive Infectious Mucocutaneous Eruption, Mucositis | | | Mycoplasma pneumoniae is a common cause of pneumonia in children, with extrapulmonary complications in approximately 25%1 of cases and dermatological manifestations in 1-5%.2
Reactive Infectious Mucocutaneous Eruption (RIME), previously referred to as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), is a severe mucocutaneous reaction that predominantly affects children and adolescents, with a mean age of 11.9 years and a male predominance of 66%.1 It is characterized by prominent mucosal involvement-typically affecting the oral, ocular and genital mucosa-with minimal or absent cutaneous lesions.1,3 Although most commonly associated with Mycoplasma pneumoniae, RIME has been increasingly recognized as a broader clinical entity triggered by various pathogens3, including Epstein–Barr virus, Enterovirus, Influenza virus, Adenovirus and SARS-CoV-2.3,4
We describe the case of an 11-year-old male with no significant medical history who presented with progressively worsening lip discomfort, followed by swelling, sloughing and crusting of the lips, along with lesions on the tongue and buccal mucosa. These symptoms were associated with dysphagia, sialorrhea and food refusal over two days. Four days prior, he had been diagnosed with community-acquired pneumonia and started on a 10-day course of oral amoxicillin-clavulanic acid (75 mg/kg/day).
On admission, he was febrile (38°C), with normal vital signs and oxygen saturation above 94% on room air. Physical examination revealed hemorrhagic crusting of the lips (Figure 1), extensive erosions on the tongue and buccal mucosa and bilateral conjunctival hyperemia without exudate. Pulmonary auscultation showed scattered crackles.
Figure 1. Oral mucositis.
Laboratory tests revealed a white blood cell count of 13,480/µL with 73% neutrophils and a C-reactive protein (CRP) of 21.3 mg/L. Chest radiograph showed bilateral interstitial infiltrates. A respiratory panel by polymerase chain reaction (PCR), including respiratory syncytial virus, adenovirus, influenza A, influenza B and SARS-CoV-2, was negative. Serology for Mycoplasma pneumoniae IgM and IgG was positive.
The patient required hospitalization due to severe oral mucositis, which impaired oral intake. He was treated with oral azithromycin (10 mg/kg/day) for 5 days and methylprednisolone (1 mg/kg/day) for 7 days, followed by a stepwise dose reduction. Amoxicillin-clavulanic acid was discontinued. Supportive care was provided including pain relief and fluid support.
Eight days after discharge, the patient showed significant clinical improvement and a visit one month later revealed no recurrence of symptoms. Serology performed at that time showed elevated IgM and IgG titers, confirming Mycoplasma pneumoniae infection.
Diagnostic criteria for RIME include vesiculobullous lesions or scattered, atypical, targetoid lesions on the skin affecting less than 10% of the body surface area, no relevant medication history, prodromal symptoms such as cough, fever and malaise typically occurring within 7 to 10 days prior to the eruption and clinical, imaging or laboratory findings suggesting an infectious trigger.5
Although a definitive treatment has not been established, management is typically symptomatic, focusing on mucosal care, pain relief and providing fluids and nutritional support.3 Systemic corticosteroids are commonly used to alleviate inflammation and pain, especially in cases with extensive mucosal involvement. Additionally, therapy is directed toward the underlying infectious cause. The prognosis of RIME is generally favorable, with most patients achieving full recovery.1 | | | | Compliance with Ethical Standards | | Funding None | | | | Conflict of Interest None | | |
- Canavan TN, Mathes EF, Frieden I, et al. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015 Feb;72(2):239-45. doi: 10.1016/j.jaad.2014.06.026. [CrossRef] [PubMed]
- Gonçalves R, Gata L, Brett A. Mycoplasma pneumoniae-associated mucositis. BMJ Case Rep. 2021 Apr 15;14(4):e239086. doi: 10.1136/bcr-2020-239086. [CrossRef] [PubMed] [PMC free article]
- Muttoni E, Hale G, Jury C, et al. Reactive infectious mucocutaneous eruption: a case series of four children. Br J Dermatol. 2024 Jun;191(Suppl 1):i134-5. doi:10.1093/bjd/ljae090.283. [CrossRef]
- Pan CX, Hussain SH. Recurrent reactive infectious mucocutaneous eruption: a retrospective cohort study. J Am Acad Dermatol. 2023 Aug;89(2):361-4. doi: 10.1016/j.jaad.2023.03.027. [CrossRef] [PubMed]
- Ramien ML, Bahubeshi A, Lara‐Corrales I, et al. Blistering severe cutaneous adverse reactions in children: proposal for paediatric‐focused clinical criteria. Br J Dermatol. 2021 Aug;185(2):447-9. doi: 10.1111/bjd.20063. [CrossRef] [PubMed]
DOI: https://doi.org/10.7199/ped.oncall.2025.86
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| Cite this article as: | | Almeida C B d, Andrade B, Gonçalves C, Lima S C. Not Just a Lung Infection: An Atypical Manifestation of Mycoplasma pneumoniae. Pediatr Oncall J. 2025;22. doi: 10.7199/ped.oncall.2025.86 |
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