Mycoplasma pneumoniae–associated mucositis

A 35-year-old man was admitted with fever (38°C), mucous sputum, bilateral conjunctivitis, painful oral ulcerations and mild discomfort while urinating. He had previously received a three-day course of azithromycin for suspected respiratory infection, without improvement. Physical examination showed bilateral conjunctivitis with severe subconjunctival hemorrhage (Figure 1) and markedly swollen, erythematous lips with oral ulcers (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.151017/-/DC1). The skin was not involved. Laboratory examination showed leukocytosis with neutrophilia and marked elevation of C-reactive protein. Serologic tests for herpes simplex virus, HIV, Epstein–Barr virus and Treponema pallidum yielded negative results, but positive titres were found for Mycoplasma pneumoniae immunoglobulins M and G. Mycoplasma pneumoniae–associated mucositis was diagnosed. Initiation of intravenous treatment with corticosteroids (tapered methylprednisolone, starting with 125 mg daily) led to remarkably rapid improvement in the ocular, oral and urinary symptoms and complete resolution of the lesions within three weeks.

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Figure 1:

Bilateral conjunctivitis with severe subconjunctival hemorrhage and erythematous lips in a 35-year-old man.

Mycoplasma pneumoniae, a common cause of community-acquired atypical pneumonia, may lead to associated extrapulmonary complications, including skin manifestations such as erythema multiforme major, in up to 25% of patients.1 Cases of M. pneumoniae infection characterized by mucositis consistent with erythema multiforme major but without skin lesions have gone by various terms, including “Fuchs syndrome” and “M. pneumoniae–associated mucositis.”1 Some authors have suggested that the latter be considered a distinct syndrome, because of its milder disease course, infrequent long-term sequelae and exceedingly rare mortality.1^,2 The condition affects predominantly children and adolescents; only a few cases with adult onset have been reported,3 perhaps because the disease is underrecognized or milder in this age group.

There are no evidence-based guidelines for treatment of M. pneumoniae–associated mucositis.1 Empiric antibiotic therapy is an effective first-line approach.3 Systemic corticosteroids and intravenous immunoglobulins may limit disease duration and severity and should be considered in severe cases, to limit the potential for complications associated with mucous membrane adhesions, especially ocular sequelae.