key: cord-1001279-8f7qczsu
authors: Ryder, C. Yoonhee; Pedersen, Elisabeth A.; Mancuso, Jennifer B.
title: Reactive Infectious Mucocutaneous Eruption Secondary to SARS-CoV-2 Virus
date: 2021-10-20
journal: JAAD Case Rep
DOI: 10.1016/j.jdcr.2021.10.007
sha: fc56ab5f3d126b3ead343ae855bb1f7e15461db9
doc_id: 1001279
cord_uid: 8f7qczsu

nan

Reactive infectious mucocutaneous eruption (RIME) is a recently proposed term used to 19 describe cases of post-infectious rash and mucositis. This entity was previously termed 20 mycoplasma-induced rash and mucositis (MIRM), however numerous cases have been 21 described with non-mycoplasma pneumoniae-associated causes. These patients are typically 22 adolescents and have a prodromal cough followed by severe mucositis of two or more mucous 23 membranes, with or without a cutaneous rash. Here, we report a case of RIME secondary to 24 SARS-CoV-2 virus that was refractory to corticosteroids and improved with cyclosporine. 25 26

A 17-year-old healthy male developed fever, fatigue, and cough, and tested positive for 28 SARS-CoV-2 virus via polymerase chain reaction (PCR). He was diagnosed with COVID-19. He 29 was initially treated at home with ibuprofen. Seven days later, he presented to the emergency 30 department with pharyngitis and painful oropharyngeal lesions. He was treated symptomatically 31 with mouthwash containing lidocaine and oral non-steroidal anti-inflammatory medications and 32 discharged. During the next two days, he experienced worsening pharyngeal exudate, 33 J o u r n a l P r e -p r o o f odynophagia, muffled voice, cervical edema, and fever, and presented again to the emergency 34 department. Physical exam revealed mucosal sloughing on labial surfaces of lips, tonsillar 35 pillars, and hard and soft palate ( Figure 1A IgG and IgM were not detected. HIV antigen and RPR were non-reactive. The patient was 45 admitted for severe mucositis. Erythrocyte sedimentation rate was 18 and C-reactive protein 46 was 16.9, but further workup for symptoms of multisystem inflammatory syndrome in children 47

(MIS-C) with complete blood count, comprehensive metabolic panel, troponin, and B-type 48 natriuretic protein (BNP) were normal. He was treated with intravenous (IV) methylprednisolone 49 1 mg/kg/day for three days, and discharged on oral prednisone 1 mg/kg/day after five days in 50 the hospital. 51

Four days after discharge, he returned to the emergency department with worsening 52 mucositis and dysuria. He again tested positive for SARS-CoV-2 virus via PCR. He was unable 53 to speak or tolerate oral intake due to pain. Physical exam revealed eroded plaques on the 54 labial mucosa, crusting in bilateral nares, and an erythematous eroded plaque on periurethral 55 meatus ( Figure 1B) . No ocular findings were noted. The patient was admitted and started on IV 56 methylprednisolone 1 mg/kg/day. He had worsening oral pain and subsequently cyclosporine (4 57 mg/kg/day) was started. After five days, his oral intake improved and he was discharged with 58 J o u r n a l P r e -p r o o f prednisone 1 mg/kg/day and cyclosporine. Three days after discharge, he demonstrated 59 complete resolution of mucosal lesions ( Figure 1C) . cross-sectional study has estimated that 11.7% of COVID-19 patients had oral mucosal 72 changes of any kind, with 3.9% having oral mucositis [9] . Here, we describe as case of RIME 73 secondary to COVID-19 with a classic MIRM-like presentation with complete resolution. 74

Mycoplasma induced rash and mucositis (MIRM) is a well-documented phenomenon, with an 75 estimated prevalence of 6.8% among those demonstrating laboratory evidence of an active other pathogens reported to cause post-infectious reactive mucositis including Chlamydophila 79 pneumoniae, human metapneumovirus, human parainfluenzavirus 2, rhinovirus, enterovirus, 80 and influenza B virus [4] . Now, MIRM is considered a form of RIME induced by Mycoplasma 81 pneumoniae infection [4] . RIME is considered a distinct entity from similar conditions with 82 mucocutaneous involvement such as Stevens Johnson syndrome/toxic epidermal necrolysis 83 and erythema multiforme (EM) [4] . In contrast to RIME, SJS/TEN is a drug-induced syndrome, 84

and EM is a syndrome most frequently induced by herpes simplex virus with has characteristic 85 targetoid skin lesions with variable mucosal involvement. RIME has predominant mucosal 86 involvement and minor skin manifestations, and the course is often milder than SJS/TEN [5, 6] . 87

The patient described had mucositis of two mucosal sites (genitourinary and oral) with no 88 cutaneous involvement. All infectious testing was negative except for PCR for COVID-19 virus, 89

implicating COVID-19 virus as the trigger for RIME. induced RIME in the absence of cutaneous findings. 98 RIME is considered self-limited, and treatment is supportive [5] . Although RIME has an 99 excellent prognosis, the estimated rate of recurrence is 8% and sequalae include scarring and 100 pigmentary changes [5] . The role of treatment with corticosteroids is unclear, and this patient 101 was noted to have progression of symptoms on corticosteroids. Cyclosporine may reduce the within 7 days of initiation of cyclosporine. However, it is also possible that this response may 104 represent natural resolution of the disease. 105 106

We describe a case of COVID-19 infection causing a mucosal syndrome consistent with 108 RIME, with complete resolution. Our findings suggest that COVID-19 may induce mucositis in 109 the absence of cutaneous symptoms or MIS-C. 110

Mucocutaneous disease and related clinical characteristics in 113 hospitalized children and adolescents with COVID-19 and multisystem inflammatory 114 syndrome in children

Cutaneous manifestations of hospitalized coronavirus disease 2019 117 patients: a report of six cases with clinicopathologic features and viral RNA in situ 118 hybridization

Frequency and Clinical Presentation of Mucocutaneous 120

Disease Due to Mycoplasma pneumoniae Infection in Children With Community-121 Acquired Pneumonia

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Mucocutaneous Eruptions in Acutely Ill Pediatric 129 Patients-Think of Mycoplasma pneumoniae (and Other Infections) First. JAMA 130 Dermatology

Oral manifestations of COVID-19 disease: A review article. 132 Dermatologic Therapy

Reactive Infectious Mucocutaneous Eruption Associated With 134 SARS-CoV-2 Infection

Treatment of Mycoplasma