PC2171: Healthy Adolescent Male with Multiple Recurrences of Mycoplasma Induced Rash and Mucositis: A Case Report

Introduction: Mycoplasma Induced Rash and Mucositis (MIRM) is a complication of mycoplasma pneumoniae (Mp) that was identified in 2015. Although it shares features with Stevens Johnson syndrome (SJS) and erythema multiforme (EM), MIRM is distinguished from other mucocutaneous syndromes by its milder course and sparser cutaneous manifestations. Several reports have described patients with recurrent MIRM but the mechanism is unclear and there are no standardized treatment guidelines.

Case Description: A 12-year-old male presents with oral and genital mucositis, and multiple scattered blisters that evolved over 24 hours (Figure 1). The pain limits his oral intake and he appears mildly dehydrated. He has burning with urination but denies urinary retention. He endorses resolving pharyngitis, rhinorrhea, and cough over 7 days, with no recorded fevers for the past 5 days. He is not taking any medications.
This patient was diagnosed with SJS in June 2017, and has experienced four subsequent episodes of MIRM since then that all required hospitalization (Table 1). His treatments have included steroids, intravenous immunoglobulins (IVIG), and antimicrobials. However, episodes have often been complicated by readmission and escalation of therapies to achieve remission. His immunologic work-up is normal and no chronic viral infections have been identified. This presentation is similar to his previous MIRM episodes though mucositis escalated more rapidly.
The patient was admitted and started on 10 mg/kg of methylprednisolone with dramatic improvement over three days. He was discharged with a 2-week steroid taper and achieved resolution of symptoms without relapse.

Discussion: A literature review from 2021 identified 27 patients with MIRM; only seven articles described recurrent MIRM. Of these 27, 11 (37%) reported treatment with up to 2mg/kg of systemic steroids; only six (21%) were treated with other therapies including IVIG and cyclosporine A. Recurrences were described as mild; still, in one case series, eight of 14 recurrences (57%) required hospital admission.
Our patient has required prolonged courses of steroids and IVIG, and suffered more recurrences with hospitalization than have been previously documented. It is speculated that recurrences of MIRM may be prevented by targeted Mp therapies, similar to use of acyclovir for EM. Recurrent Mp has only been documented in immunocompromised patients to date. Our patient continues to have MIRM episodes despite aggressive antibiotic treatments. Although his Mp antibodies are elevated with episodes, molecular testing has been negative.

Conclusion: This case provides some evidence for amending our understanding of the role that Mp may play in triggering recurrent MIRM. Higher doses of systemic steroids may be necessary to achieve durable remissions in some patients. The role of targeted antimicrobials remains unclear though our experience does not support use of this treatment modality.