In the Journals

Community-acquired pneumonia may lead to mucocutaneous manifestations in children

Mucocutaneous manifestations were significantly more likely in children with community-acquired pneumonia due to Mycoplasma pneumoniae than in children with community-acquired pneumonia of other etiologies, according to a cohort study.

“Early recognizing inflammatory lesions of the skin and mucous membranes as infection-triggered rather than drug-triggered enables more specific treatment and, most importantly, avoids restriction of possibly causative drugs,” Patrick M. Meyer Sauteur, MD, PhD, consultant in pediatric infectious diseases and hospital epidemiology at University Children’s Hospital Zurich, said in a press release.

Meyer Sauteur and colleagues aimed to use improved diagnostics to gain further understanding of the frequency and clinical presentation of M. pneumoniae-induced mucocutaneous disease in children with community-acquired pneumonia (CAP).

The 152 eligible participants for the prospective, longitudinal cohort study were enrolled at the University Children’s Hospital Zurich between May 1, 2016, and April 30, 2017. Patients were aged 3 to 18 years and treated on an inpatient or outpatient basis for clinically defined CAP.

Among 44 patients who tested positive for M. pneumoniae by PCR, 10 (22.7%) developed mucocutaneous lesions.

Positive specific IgM antibody-secreting cell tests were reported in all 10 patients with mucocutaneous eruptions. Clinicians observed that 2.8% of patients with M. pneumoniae PCR-negative CAP had skin manifestations (P < .001).

M. pneumoniae-induced mucocutaneous disease manifested in several ways, including rash and mucositis, which occurred in 6.8% of those patients, urticaria (4.5%) and maculopapular skin eruptions (11.4%).

Ocular involvement as the only mucosal manifestation was observed in two patients. One case involved bilateral anterior uveitis, while the other was nonpurulent conjunctivitis.

A longer duration of prodromal fever was reported in patients with M pneumoniae-induced mucocutaneous disease compared with patients with CAP due to M. pneumoniae without mucocutaneous manifestations (median, 10.5 days [range, 8.3 to 11.8] vs. 7.0 days [range, 5.5 to 9.5]; P = .02). Similarly, higher C-reactive protein levels occurred in the mucocutaneous manifestations group (median, 31 mg/L [range, 22 to 59] vs. 16 mg/L [range, 7 to 23]; P=.04).

Patients with mucocutaneous manifestations also required oxygen at higher rates (50% vs. 5%; P = .007), required more hospitalizations (70% vs. 19%; P = .01) and were more likely to develop long-term sequelae (30% vs. 0%; P = .03).

“This leads to an interesting conclusion: It may be not M. pneumoniae itself that causes the skin and mucous membrane lesions, but the immune system, which reacts to the bacteria,” Meyer Sauteur said in the release.

Anna L. Bruckner, MD , MSCS , of the University of Colorado School of Medicine, and Michele L. Ramien, MDCM, of Alberta Children’s Hospital and the University of Calgary, wrote an editorial accompanying the study. “In children and adolescents, an acute-onset mucosal-predominant eruption with a respiratory illness prodrome and without a highly worrisome medication is most likely [reactive infectious mucocutaneous eruption/M. pneumoniae-induced rash and mucositis (RIME/MIRM)], not [drug-induced toxic epidermal necrolysis/toxic epidermal necrolysis],” they wrote.

The editorialists suggested that M. pneumoniae is the most common cause of CAP in children who were admitted to the hospital but that PCR and other common tests often fail to distinguish between true M. pneumoniae and a so-called “innocent bystander,” or M. pneumoniae carriage.

“Thus, recognition of RIME/MIRM caused by M. pneumoniae and other infections as highlighted by Meyer Sauteur and colleagues has benefits for immediate and long-term management,” Brucker and Ramien wrote. “Immediate management includes initiation of appropriate antibiotics to treat confirmed CAP, although antibiotics do not seem to influence the course of the RIME/MIRM mucocutaneous eruption. ... Long-term management entails surveillance for sequelae and recurrences and preventing the label of severe medication allergy.” – by Rob Volansky

Disclosure s : Meyer Sauteur reports receiving grants from a Fellowship Award of the European Society for Pediatric Infectious Diseases, the Promedica Foundation and the Starr International Foundation. Brucker and Ramien report no relevant financial disclosures.

Mucocutaneous manifestations were significantly more likely in children with community-acquired pneumonia due to Mycoplasma pneumoniae than in children with community-acquired pneumonia of other etiologies, according to a cohort study.

“Early recognizing inflammatory lesions of the skin and mucous membranes as infection-triggered rather than drug-triggered enables more specific treatment and, most importantly, avoids restriction of possibly causative drugs,” Patrick M. Meyer Sauteur, MD, PhD, consultant in pediatric infectious diseases and hospital epidemiology at University Children’s Hospital Zurich, said in a press release.

Meyer Sauteur and colleagues aimed to use improved diagnostics to gain further understanding of the frequency and clinical presentation of M. pneumoniae-induced mucocutaneous disease in children with community-acquired pneumonia (CAP).

The 152 eligible participants for the prospective, longitudinal cohort study were enrolled at the University Children’s Hospital Zurich between May 1, 2016, and April 30, 2017. Patients were aged 3 to 18 years and treated on an inpatient or outpatient basis for clinically defined CAP.

Among 44 patients who tested positive for M. pneumoniae by PCR, 10 (22.7%) developed mucocutaneous lesions.

Positive specific IgM antibody-secreting cell tests were reported in all 10 patients with mucocutaneous eruptions. Clinicians observed that 2.8% of patients with M. pneumoniae PCR-negative CAP had skin manifestations (P < .001).

M. pneumoniae-induced mucocutaneous disease manifested in several ways, including rash and mucositis, which occurred in 6.8% of those patients, urticaria (4.5%) and maculopapular skin eruptions (11.4%).

Ocular involvement as the only mucosal manifestation was observed in two patients. One case involved bilateral anterior uveitis, while the other was nonpurulent conjunctivitis.

A longer duration of prodromal fever was reported in patients with M pneumoniae-induced mucocutaneous disease compared with patients with CAP due to M. pneumoniae without mucocutaneous manifestations (median, 10.5 days [range, 8.3 to 11.8] vs. 7.0 days [range, 5.5 to 9.5]; P = .02). Similarly, higher C-reactive protein levels occurred in the mucocutaneous manifestations group (median, 31 mg/L [range, 22 to 59] vs. 16 mg/L [range, 7 to 23]; P=.04).

Patients with mucocutaneous manifestations also required oxygen at higher rates (50% vs. 5%; P = .007), required more hospitalizations (70% vs. 19%; P = .01) and were more likely to develop long-term sequelae (30% vs. 0%; P = .03).

“This leads to an interesting conclusion: It may be not M. pneumoniae itself that causes the skin and mucous membrane lesions, but the immune system, which reacts to the bacteria,” Meyer Sauteur said in the release.

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Anna L. Bruckner, MD , MSCS , of the University of Colorado School of Medicine, and Michele L. Ramien, MDCM, of Alberta Children’s Hospital and the University of Calgary, wrote an editorial accompanying the study. “In children and adolescents, an acute-onset mucosal-predominant eruption with a respiratory illness prodrome and without a highly worrisome medication is most likely [reactive infectious mucocutaneous eruption/M. pneumoniae-induced rash and mucositis (RIME/MIRM)], not [drug-induced toxic epidermal necrolysis/toxic epidermal necrolysis],” they wrote.

The editorialists suggested that M. pneumoniae is the most common cause of CAP in children who were admitted to the hospital but that PCR and other common tests often fail to distinguish between true M. pneumoniae and a so-called “innocent bystander,” or M. pneumoniae carriage.

“Thus, recognition of RIME/MIRM caused by M. pneumoniae and other infections as highlighted by Meyer Sauteur and colleagues has benefits for immediate and long-term management,” Brucker and Ramien wrote. “Immediate management includes initiation of appropriate antibiotics to treat confirmed CAP, although antibiotics do not seem to influence the course of the RIME/MIRM mucocutaneous eruption. ... Long-term management entails surveillance for sequelae and recurrences and preventing the label of severe medication allergy.” – by Rob Volansky

Disclosure s : Meyer Sauteur reports receiving grants from a Fellowship Award of the European Society for Pediatric Infectious Diseases, the Promedica Foundation and the Starr International Foundation. Brucker and Ramien report no relevant financial disclosures.