array:24 [
  "pii" => "S1578219016301366"
  "issn" => "15782190"
  "doi" => "10.1016/j.adengl.2016.06.005"
  "estado" => "S300"
  "fechaPublicacion" => "2016-09-01"
  "aid" => "1372"
  "copyright" => "Elsevier España, S.L.U. and AEDV"
  "copyrightAnyo" => "2016"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Actas Dermosifiliogr. 2016;107:e47-51"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 3827
    "formatos" => array:3 [
      "EPUB" => 46
      "HTML" => 3311
      "PDF" => 470
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0001731016000922"
      "issn" => "00017310"
      "doi" => "10.1016/j.ad.2015.09.023"
      "estado" => "S300"
      "fechaPublicacion" => "2016-09-01"
      "aid" => "1372"
      "copyright" => "AEDV"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "crp"
      "cita" => "Actas Dermosifiliogr. 2016;107:e47-51"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 751
        "formatos" => array:3 [
          "EPUB" => 4
          "HTML" => 638
          "PDF" => 109
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">e-Casos cl&#237;nicos</span>"
        "titulo" => "Exantema mucocut&#225;neo inducido por <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#58; &#191;un nuevo s&#237;ndrome separado del eritema multiforme&#63; Un nuevo caso y revisi&#243;n de la literatura"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "e47"
            "paginaFinal" => "e51"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "<span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>-Induced Mucocutaneous Rash&#58; A New Syndrome Distinct from Erythema Multiforme&#63; Report of a New Case and Review of the Literature"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1662
                "Ancho" => 1500
                "Tamanyo" => 338669
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#46; Hiperemia conjuntival con secreci&#243;n bilateral&#46; B&#46; P&#225;pulas eritematoedematosas&#44; irregulares&#44; con vesiculaci&#243;n central y un halo eritematoso&#44; formando &#171;dianas&#187; at&#237;picas palpables&#44; diseminadas por la cara&#44; el tronco&#44; los miembros y las mucosas perineal y genital&#44; respetando las palmas y las plantas&#46; C&#46; Erosiones&#44; &#250;lceras confluentes y costras en los labios y la mucosa&#46; D&#46; Evoluci&#243;n de las lesiones cut&#225;neas a los 2 d&#237;as de inicio del exantema&#46; E&#46; Detalle de las lesiones en forma de diana at&#237;pica&#46; &#40;ver estrella en 1B&#41;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "M&#46; Mart&#237;nez-P&#233;rez, A&#46; Imbern&#243;n-Moya, A&#46; Lobato-Berezo, M&#46; Churruca-Grijelmo"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "Mart&#237;nez-P&#233;rez"
              ]
              1 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Imbern&#243;n-Moya"
              ]
              2 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Lobato-Berezo"
              ]
              3 => array:2 [
                "nombre" => "M&#46;"
                "apellidos" => "Churruca-Grijelmo"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1578219016301366"
          "doi" => "10.1016/j.adengl.2016.06.005"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301366?idApp=UINPBA000044"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016000922?idApp=UINPBA000044"
      "url" => "/00017310/0000010700000007/v2_201609150132/S0001731016000922/v2_201609150132/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1578219016301378"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2016.06.006"
    "estado" => "S300"
    "fechaPublicacion" => "2016-09-01"
    "aid" => "1356"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and AEDV"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Actas Dermosifiliogr. 2016;107:e52-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 830
      "formatos" => array:3 [
        "EPUB" => 62
        "HTML" => 594
        "PDF" => 174
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">e- Case Report</span>"
      "titulo" => "Distant Cutaneous Metastases of Prostate Cancer&#58; A Report of 2 Cases"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "e52"
          "paginaFinal" => "e56"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Met&#225;stasis cut&#225;neas a distancia de c&#225;ncer de pr&#243;stata&#58; 2 casos"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 1211
              "Ancho" => 1500
              "Tamanyo" => 458418
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; A&#44; Hematoxylin-eosin&#46; B&#44; Prostatic acid phosphatase&#44; original magnification x100&#46; C&#44; Prostate specific membrane antigen&#44; original magnification x100&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "R&#46; Rodr&#237;guez-Lojo, I&#46; Casti&#241;eiras, J&#46;L&#46; Rey-Sanjurjo, M&#46;L&#46; Fern&#225;ndez-D&#237;az"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "R&#46;"
              "apellidos" => "Rodr&#237;guez-Lojo"
            ]
            1 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Casti&#241;eiras"
            ]
            2 => array:2 [
              "nombre" => "J&#46;L&#46;"
              "apellidos" => "Rey-Sanjurjo"
            ]
            3 => array:2 [
              "nombre" => "M&#46;L&#46;"
              "apellidos" => "Fern&#225;ndez-D&#237;az"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731016000697"
        "doi" => "10.1016/j.ad.2015.09.021"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016000697?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301378?idApp=UINPBA000044"
    "url" => "/15782190/0000010700000007/v2_201704140340/S1578219016301378/v2_201704140340/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1578219016301846"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2016.04.005"
    "estado" => "S300"
    "fechaPublicacion" => "2016-09-01"
    "aid" => "1428"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Actas Dermosifiliogr. 2016;107:591-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 1113
      "formatos" => array:3 [
        "EPUB" => 45
        "HTML" => 857
        "PDF" => 211
      ]
    ]
    "en" => array:14 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
      "titulo" => "Alexandrite Laser for the Treatment of Resistant and Hypertrophic Port Wine Stains&#58; A Clinical&#44; Histological and Histochemical Study"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:3 [
        0 => "en"
        1 => "en"
        2 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "591"
          "paginaFinal" => "596"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Laser de Alejandrita para el tratamiento de malformaciones capilares tipo mancha en vino de Oporto resistentes y&#47;o hipertr&#243;ficas&#58; estudio cl&#237;nico&#44; histol&#243;gico e histoqu&#237;mico"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 1
        "multimedia" => array:5 [
          "identificador" => "fig0025"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => false
          "mostrarDisplay" => true
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "fx1.jpeg"
              "Alto" => 886
              "Ancho" => 1330
              "Tamanyo" => 123456
            ]
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "E&#46; Grillo, P&#46; Gonz&#225;lez-Mu&#241;oz, P&#46; Boixeda, A&#46; Cuevas, S&#46; Va&#241;&#243;, P&#46; Ja&#233;n"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Grillo"
            ]
            1 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Gonz&#225;lez-Mu&#241;oz"
            ]
            2 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Boixeda"
            ]
            3 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Cuevas"
            ]
            4 => array:2 [
              "nombre" => "S&#46;"
              "apellidos" => "Va&#241;&#243;"
            ]
            5 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Ja&#233;n"
            ]
          ]
        ]
      ]
      "resumen" => array:1 [
        0 => array:3 [
          "titulo" => "Graphical abstract"
          "clase" => "graphical"
          "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><elsevierMultimedia ident="fig0025"></elsevierMultimedia></p></span>"
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S000173101630134X"
        "doi" => "10.1016/j.ad.2016.04.016"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000173101630134X?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301846?idApp=UINPBA000044"
    "url" => "/15782190/0000010700000007/v2_201704140340/S1578219016301846/v2_201704140340/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">e-Casos cl&#237;nicos</span>"
    "titulo" => "<span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>-Induced Mucocutaneous Rash&#58; A New Syndrome Distinct from Erythema Multiforme&#63; Report of a New Case and Review of the Literature"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "e47"
        "paginaFinal" => "e51"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "M&#46; Mart&#237;nez-P&#233;rez, A&#46; Imbern&#243;n-Moya, A&#46; Lobato-Berezo, M&#46; Churruca-Grijelmo"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "M&#46;"
            "apellidos" => "Mart&#237;nez-P&#233;rez"
            "email" => array:1 [
              0 => "mrcl&#95;mtnez&#64;yahoo&#46;es"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "A&#46;"
            "apellidos" => "Imbern&#243;n-Moya"
          ]
          2 => array:2 [
            "nombre" => "A&#46;"
            "apellidos" => "Lobato-Berezo"
          ]
          3 => array:2 [
            "nombre" => "M&#46;"
            "apellidos" => "Churruca-Grijelmo"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Servicio de Dermatolog&#237;a y Venereolog&#237;a&#44; Hospital Severo Ochoa&#44; Madrid&#44; Spain"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Exantema mucocut&#225;neo inducido por <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#58; &#191;un nuevo s&#237;ndrome separado del eritema multiforme&#63; Un nuevo caso y revisi&#243;n de la literatura"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 736
            "Ancho" => 925
            "Tamanyo" => 94091
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pneumonia infiltrate in the right upper lobe &#40;arrow&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> infection affects the skin and mucosas in up to 25&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> and can cause erythema multiforme &#40;EM&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> and Stevens-Johnson syndrome&#47;toxic epidermal necrolysis &#40;SJS&#47;TEN&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> The clinical overlap between these conditions&#44; which has led to long-standing debate in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#8211;9</span></a> makes diagnosis difficult in some cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">10&#44;11</span></a> An extensive review of 202 cases of <span class="elsevierStyleItalic">M&#160;pneumoniae</span>-induced EM&#44; SJS&#44; and mucositis without rash was published recently&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> In their conclusions&#44; the authors proposed a new entity which they called <span class="elsevierStyleItalic">Mycoplasma-induced rash and mucositis</span>&#46; We present a case that we found difficult to classify and that was consistent with the new entity described&#46; As suggested by those authors&#44; we believe this entity could be helpful in the diagnosis and treatment of these cases in daily practice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Description</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient&#44; a previously healthy 16-year-old girl&#44; presented a 7-day history of fever of 38&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; odynophagia&#44; cough&#44; and wheeze&#46; She was diagnosed with acute bronchitis and received treatment with inhaled budesonide and ibuprofen&#46; She was subsequently seen for the rapid onset of lesions on the skin and mucosas&#46; She had not received other drugs and she did not report a history of herpes infection&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed intense stomatitis with confluent ulcers and scabs affecting all of the lips and the oral&#44; palatine&#44; and pharyngeal mucosas&#44; associated with bilateral conjunctival hyperemia with discharge&#46; Numerous irregular&#44; edematous erythematous plaques with central vesicles and an erythematous halo&#44; giving them the appearance of atypical target lesions&#44; were observed on the skin of the face&#44; trunk&#44; limbs&#44; perineum&#44; and genital mucosa &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The palms and soles were not affected&#46; No tonsillar exudate was observed and there were no palpable lymph nodes in the head and neck&#46; Auscultation of the chest revealed crepitations&#46; Abdominal examination was normal&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was admitted with a clinical suspicion of erythema multiforme major secondary to <span class="elsevierStyleItalic">M pneumoniae</span> infection&#46; Laboratory tests were as follows&#58; C-reactive protein&#44; 21<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; anti-streptolysin O titer&#44; 222<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#59; white cell count&#44; 22<span class="elsevierStyleHsp" style=""></span>850<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L &#40;82&#46;3&#37; neutrophils&#44; with no atypical lymphocytes&#41;&#59; <span class="elsevierStyleItalic">M pneumoniae</span> IgM antibody&#44; 292<span class="elsevierStyleHsp" style=""></span>U&#59; herpes simplex virus&#44; Epstein-Barr virus&#44; and cytomegalovirus serology&#44; negative&#46; Chest x-ray showed a pneumonia infiltrate in the right upper lobe &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Skin biopsy revealed an intense vacuolar interface lesion&#44; isolated necrotic keratinocytes&#44; and extensive dermoepidermal separation&#44; with no epithelial necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment was started with intravenous methylprednisolone&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; clarithromycin&#44; and acyclovir&#46; The acyclovir was withdrawn after the serology results were received&#46; Topical corticosteroids and antibiotics were applied to the conjunctival and oral mucosas&#44; and fluid support and analgesia were administered until the patient&#39;s condition improved&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The skin lesions increased for a further 3 days&#44; affecting up to 20&#37; of the body surface&#44; and took on a crusted&#44; purpuric appearance&#44; with lesions simultaneously observed in distinct stages&#46; Some lesions developed flaccid blisters that did not coalesce or rupture&#46; The Nikolski sign was negative and exfoliation did not occur&#46; After 10 days the patient&#39;s condition had improved sufficiently for her to be discharged with only a residual hyperpigmentation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M pneumoniae</span> is implicated in up to 40&#37; of atypical pneumonias&#44; particularly in children and young adults&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> It provokes changes in the skin in up to a fourth of patients&#44; with nonspecific rash being most common&#44; though stomatitis&#44; vaginal ulcers&#44; pityriasis rosea&#44; Kawasaki disease&#44; leukocytoclastic vasculitis&#44; subcorneal pustular dermatosis&#44; Sweet syndrome&#44; thrombotic thrombocytopenic purpura&#44; Raynaud disease&#44; Henoch-Schonlein purpura&#44; and other conditions are also observed&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> The exact incidence of EM in children and young adults who develop infection due to <span class="elsevierStyleItalic">M pneumoniae</span> and other <span class="elsevierStyleItalic">Mycoplasma</span> species<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> is unknown&#44; while that of SJS has been estimated at approximately 5&#37;&#44; though these data may be affected by the confusing nomenclature&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">10&#44;11</span></a> Because of the clinical overlap between these syndromes&#44; EM&#44; SJS&#44; and TEN have for decades been considered part of a spectrum&#46; However&#44; the Severe Cutaneous Adverse Reactions study concluded that EM and SJS&#47;TEN can be separated into 2 distinct groups based on their clinical characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> A later multicenter study confirmed the validity of that classification and its correlation with etiologic and prognostic factors&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> and the 2 conditions are now considered separate entities&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> It was difficult to confidently classify our patient into 1 of these groups&#44; because the infectious origin&#44; the acute onset&#44; the target morphology of the lesions&#44; and the favorable clinical course supported a diagnosis of EM&#44; while the general symptoms&#44; the central distribution with centripetal spread&#44; and the large area affected by the lesions&#44; together with intense involvement of 3 mucosas&#44; was consistent with SJS&#46; The differences between these conditions are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In a study recently published by Canavan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> the authors reviewed the epidemiological and clinical characteristics of the 202 published cases of mucocutaneous rash associated with <span class="elsevierStyleItalic">M pneumoniae</span>&#46; Their results&#44; which we summarize here&#44; led them to propose the creation of a new entity separate from the EM spectrum&#46; Their patients were young &#40;mean age&#44; 11&#46;9 years&#41;&#44; with prodromal symptoms consisting of cough&#44; malaise&#44; and fever the week prior to the skin rash&#46; The distribution of the lesions was acral in 46&#37;&#44; widespread in 31&#37;&#44; and on the trunk in 23&#37;&#59; lesion morphology was variable&#44; the most common forms being vesicles and blisters &#40;77&#37;&#41; and target lesions &#40;48&#37;&#41;&#46; Mucosal involvement was intense and was fundamental to the diagnosis&#46; Most common was oral mucositis&#44; which occurred in 94&#37; of cases&#44; followed by bilateral purulent conjunctivitis &#40;82&#37;&#41; and involvement of the urogenital mucosa &#40;63&#37;&#41;&#46; The mean number of mucosas affected was 2&#46;5&#46; The disease had a benign course in the majority of patients&#44; with complete recovery in 81&#37;&#46; Only 4&#37; of patients required management in an intensive care unit according to that review article&#44; and the estimated mortality was 3&#37;&#46; Patients were mainly treated with antibiotics &#40;80&#37;&#41; and systemic corticosteroids &#40;35&#37;&#41;&#59; a minority &#40;8&#37;&#41; received intravenous immunoglobulin&#46; Recurrence rates were not particularly high &#40;8&#37;&#41;&#46; Those authors concluded that the etiology&#44; lesion morphology&#44; and clinical course&#44; as well as the potentially distinct treatment of these patients&#44; justified the designation of a clinical entity distinct from classic herpes simplex virus-associated EM and from drug-induced SJS&#47;TEN&#46; They proposed the term <span class="elsevierStyleItalic">Mycoplasma-induced rash and mucositis</span> &#40;MIRM&#41;&#46; This new classification is particularly useful in cases of extensive mucositis due to <span class="elsevierStyleItalic">M pneumoniae</span> without skin rash &#40;<span class="elsevierStyleItalic">MIRM sine rash</span> for those authors&#41;&#44; which did not adapt to the previous classifications and which could be due to certain strains of <span class="elsevierStyleItalic">M pneumoniae</span>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The etiologic and pathogenic hypothesis is that MIRM is caused by the production of immunoglobulins by proliferating clones of B cells&#44; and that this leads to immune complex deposition in the skin and to the activation of complement&#46; This also differentiates the condition from EM and from SJS&#47;TEN&#44; which are caused by a type <span class="elsevierStyleSmallCaps">IV</span> delayed hypersensitivity reaction and by Fas-ligand-mediated cytotoxicity&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Our case is compatible with those described by Canavan et al&#46;&#44; and its classification within this new entity would dispel the diagnostic doubts that persisted after applying the criteria of the Severe Cutaneous Adverse Reactions study&#46; We would therefore favor accepting the proposal of those authors&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The classification of the severe mucocutaneous diseases secondary to infections and drugs is complex due to the clinical overlap between them&#46; After decades of controversy&#44; EM was separated from SJS&#47;TEN in 2002&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> Likewise&#44; in 2013&#44; drug reaction with eosinophilia and systemic symptoms &#40;DRESS&#41; was separated from the SJS spectrum&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> Acceptance of MIRM as an independent entity could facilitate correct diagnosis and more adequate treatment of our patients&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this research&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:12 [
        0 => array:3 [
          "identificador" => "xres828173"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec824412"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres828174"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec824411"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Description"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusion"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of Interest"
        ]
        10 => array:2 [
          "identificador" => "xack277918"
          "titulo" => "Acknowledgments"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec824412"
          "palabras" => array:7 [
            0 => "<span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>"
            1 => "Erythema multiforme"
            2 => "Stevens-Johnson syndrome"
            3 => "Rash"
            4 => "Mucositis"
            5 => "Clinical classification"
            6 => "Treatment"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec824411"
          "palabras" => array:7 [
            0 => "<span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>"
            1 => "Eritema multiforme"
            2 => "S&#237;ndrome de Stevens-Johnson"
            3 => "Exantema"
            4 => "Mucositis"
            5 => "Clasificaci&#243;n cl&#237;nica"
            6 => "Tratamiento"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Respiratory tract infection due to <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> can provoke cutaneous and mucosal rashes&#44; which have been classified within the spectrum of erythema multiforme or Stevens-Johnson syndrome&#46; This classification is of therapeutic and prognostic importance and has generated intense debate in the literature&#46; A recent systematic review of 202 cases of mucocutaneous rashes associated with <span class="elsevierStyleItalic">M&#46;&#160;pneumoniae</span> infection concluded that these rashes might constitute a distinct entity&#44; for which the term <span class="elsevierStyleItalic">Mycoplasma</span>-induced rash and mucositis was proposed&#46; We describe a patient with acute <span class="elsevierStyleItalic">M&#160;pneumoniae</span> respiratory tract infection who presented mucosal and cutaneous lesions that were difficult to classify as erythema multiforme or Stevens-Johnson syndrome&#59; the lesions were compatible with the proposed new disease&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La infecci&#243;n respiratoria por <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> &#40;MP&#41; puede producir erupciones cut&#225;neo-mucosas que se han considerado parte del espectro eritema multiforme o del s&#237;ndrome de Stevens-Johnson&#46; La clasificaci&#243;n de estas reacciones cut&#225;neas&#44; que tiene importancia pron&#243;stica y terap&#233;utica&#44; ha generado mucha controversia en la literatura&#46; Recientemente&#44; una revisi&#243;n sistem&#225;tica de 202 casos de erupciones mucocut&#225;neas asociadas a infecci&#243;n por MP concluye que pueden constituir una entidad distinta para la que se propone la expresi&#243;n <span class="elsevierStyleItalic">Mycoplasma</span>-<span class="elsevierStyleItalic">induced rash and mucositis</span>&#46; Presentamos un caso de infecci&#243;n respiratoria aguda por MP con lesiones mucosas y cut&#225;neas dif&#237;ciles de clasificar como eritema multiforme o s&#237;ndrome de Stevens-Johnson&#44; y cuyas caracter&#237;sticas son compatibles con la nueva enfermedad propuesta&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Mart&#237;nez-P&#233;rez M&#44; Imbern&#243;n-Moya A&#44; Lobato-Berezo A&#44; Churruca-Grijelmo M&#46; Exantema mucocut&#225;neo inducido por <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#58; &#191;un nuevo s&#237;ndrome separado del eritema multiforme&#63; Un nuevo caso y revisi&#243;n de la literatura&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e47&#8211;e51&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1663
            "Ancho" => 1500
            "Tamanyo" => 352147
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Bilateral conjunctival hyperemia with discharge&#46; B&#44; Irregular&#44; edematous erythematous papules with central vesicles and an erythematous halo&#44; forming palpable atypical target lesions&#44; widespread over the face&#44; trunk&#44; limbs&#44; and perineal and genital mucosas&#44; without affecting the palms and soles&#46; C&#44; Erosions&#44; confluent ulcers&#44; and scabs on the lips and mucosa&#46; D&#44; Changes in the skin lesions 2 days after onset of the rash&#46; E&#44; Detail of the atypical target lesions &#40;corresponds to the area of the star in image B&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 736
            "Ancho" => 925
            "Tamanyo" => 94091
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pneumonia infiltrate in the right upper lobe &#40;arrow&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 742
            "Ancho" => 990
            "Tamanyo" => 247691
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Histopathology&#58; extensive vacuolar interface lesion&#44; isolated necrotic keratinocytes&#44; and extensive dermoepidermal separation with no epithelial necrosis&#46; Hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>x10&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; EM&#44; erythema multiforme&#59; HSV&#44; herpes simplex virus&#59; SJS&#44; Stevens-Johnson syndrome&#59; TEN&#44; toxic epidermal necrolysis&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Epidemiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Basic Lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Extension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prognosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">M pneumoniae</span>-induced rash and mucositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12 y<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a><br><br>Prodrome of respiratory tract infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">M pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vesicles&#44; blisters&#44; mucositis &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>2 mucosas&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Variable<br>Predominantly acral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Favorable<br><br>8&#37; recurrence rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macrolides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25 y<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a><br><br>History of HSV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#37; HSV<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> &#40;5&#37; drug-related&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated typical&#47;atypical target lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Favorable&#44; 30&#37; recurrence rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Symptomatic<br><br>Consider HSV suppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SJS spectrum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Mean age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45 y<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a><br><br>Drug exposure</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">45&#37; drug-related<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a><br><br>Other diseases &#40;collagen disease&#44; HIV&#44; tumors&#44; 15&#37; HSV&#41;</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Flat atypical target lesions<br><br>Blisters arising on macules and patches</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Trunk</td><td class="td" title="table-entry  " align="left" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#37;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Withdrawal of the causative drugs<br><br>Supportive measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SJS&#47;TEN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10-30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#37;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TEN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;<span class="elsevierStyleHsp" style=""></span>30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&#37;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1393482.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Mortality&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Differences Between <span class="elsevierStyleItalic">Mycoplasma</span>-Induced Rash and Mucositis&#44; Erythema Multiforme&#44; and Stevens-Johnson Syndrome&#47;Toxic Epidermal Necrolysis Spectrum&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:14 [
            0 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mycoplasma pneumoniae infection associated with bullous erythema multiforme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;C&#46; Schalock"
                            1 => "J&#46;B&#46; Brennick"
                            2 => "J&#46;G&#46; Dinulos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2004.11.074"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2005"
                        "volumen" => "52"
                        "paginaInicial" => "705"
                        "paginaFinal" => "706"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15793531"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recurrent erythema multiforme in association with recurrent <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Grosber"
                            1 => "M&#46; Alexandre"
                            2 => "E&#46; Poszepczynska-Guigne"
                            3 => "J&#46; Revuz"
                            4 => "J&#46;C&#46; Roujeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2006.05.047"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2007"
                        "volumen" => "56"
                        "paginaInicial" => "S118"
                        "paginaFinal" => "S119"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17434037"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mycoplasma pneumoniae infection is associated with Stevens-Johnson syndrome&#44; not erythema multiforme &#40;von Hebra&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Y&#46;K&#46; Tay"
                            1 => "J&#46;C&#46; Huff"
                            2 => "W&#46;L&#46; Weston"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAAD"
                        "fecha" => "1996"
                        "volumen" => "35"
                        "paginaInicial" => "757"
                        "paginaFinal" => "760"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8912572"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "What is going on in erythema multiforme&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;C&#46; Roujeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Dermatology"
                        "fecha" => "1994"
                        "volumen" => "188"
                        "paginaInicial" => "249"
                        "paginaFinal" => "250"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8193394"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0302283809008604"
                          "estado" => "S300"
                          "issn" => "03022838"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical classification of cases of toxic epidermal necrolysis&#44; Stevens-Johnson syndrome and erythema multiforme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Bastuji-Garin"
                            1 => "B&#46; Rzany"
                            2 => "R&#46;S&#46; Stern"
                            3 => "N&#46;H&#46; Shear"
                            4 => "L&#46; Naldi"
                            5 => "J&#46;C&#46; Roujeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1993"
                        "volumen" => "129"
                        "paginaInicial" => "92"
                        "paginaFinal" => "96"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8420497"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The spectrum of Stevens-Johnson syndrome and toxic epidermal necrolysis&#58; A clinical classification"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;C&#46; Roujeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Investigative Dermat"
                        "fecha" => "1994"
                        "volumen" => "102"
                        "paginaInicial" => "28"
                        "paginaFinal" => "30"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Erythema multiforme with mucous membrane involvement and Stevens-Johnson syndrome are clinically different disorders with distinct causes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Assier"
                            1 => "S&#46; Bastuji-garin"
                            2 => "J&#46; Revuz"
                            3 => "J&#46;C&#46; Roujeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1995"
                        "volumen" => "131"
                        "paginaInicial" => "539"
                        "paginaFinal" => "543"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7741539"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correlations between clinical patterns and causes of erythema multiforme majus&#44; Stevens-Johnson syndrome and toxic epidermal necrolysis&#58; Results of an international prospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Auquier&#95;Dunant"
                            1 => "M&#46; Mockenhaupt"
                            2 => "L&#46; Naldi"
                            3 => "O&#46; Correia"
                            4 => "W&#46; Schr&#246;der"
                            5 => "J&#46;C&#46; Roujeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "2002"
                        "volumen" => "138"
                        "paginaInicial" => "1019"
                        "paginaFinal" => "1024"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12164739"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0022534710042783"
                          "estado" => "S300"
                          "issn" => "00225347"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "S&#237;ndrome de Stevens-Johnson y necr&#243;lisis epid&#233;rmica t&#243;xica&#58; experiencia cl&#237;nica y revisi&#243;n de la literatura especializada"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Laguna"
                            1 => "B&#46; Mart&#237;n"
                            2 => "A&#46; Torrijos"
                            3 => "M&#46;L&#46; Garc&#237;a-Melgares"
                            4 => "I&#46; Febrer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
                        "fecha" => "2006"
                        "volumen" => "97"
                        "paginaInicial" => "177"
                        "paginaFinal" => "185"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16796964"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis&#44; classification and management of erythema multiforme and Stevens-Johnson syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Leaut&#233;-Labreze"
                            1 => "T&#46; Lamireau"
                            2 => "D&#46; Chawki"
                            3 => "J&#46; Maleville"
                            4 => "A&#46; Ta&#239;eb"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dis Child"
                        "fecha" => "2000"
                        "volumen" => "83"
                        "paginaInicial" => "347"
                        "paginaFinal" => "352"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10999875"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Erythema multiforme due to Mycoplasma pneumoniae infection in two children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "P&#46;C&#46; Schalock"
                            1 => "J&#46;G&#46;H&#46; Dinulos"
                            2 => "N&#46; Pace"
                            3 => "K&#46; Schwarzenberger"
                            4 => "J&#46;K&#46; Wenger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1525-1470.2006.00307.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Dermatol"
                        "fecha" => "2006"
                        "volumen" => "23"
                        "paginaInicial" => "546"
                        "paginaFinal" => "555"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17155996"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme&#46; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46;N&#46; Canavan"
                            1 => "E&#46;F&#46; Mathes"
                            2 => "I&#46; Frieden"
                            3 => "K&#46; Shinkai"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2014.06.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2015"
                        "volumen" => "72"
                        "paginaInicial" => "239"
                        "paginaFinal" => "245"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25592340"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exudado uretral y afectaci&#243;n mucocut&#225;nea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Toledo-Pastrana"
                            1 => "A&#46; Zapata-L&#243;pez"
                            2 => "A&#46; Mich&#225;n-Do&#241;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2014.04.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2014"
                        "volumen" => "214"
                        "paginaInicial" => "e91"
                        "paginaFinal" => "e92"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24889773"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug reaction with eosinophilia and systemic symptoms &#40;DRESS&#41;&#58; An original multisystem adverse drug reaction&#59; results from the prospective RegiSCAR study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;H&#46; Kardaun"
                            1 => "P&#46; Sekula"
                            2 => "L&#46; Valeyrie-Allanore"
                            3 => "Y&#46; Liss"
                            4 => "C&#46;Y&#46; Chu"
                            5 => "D&#46; Creamer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bjd.12501"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2013"
                        "volumen" => "169"
                        "paginaInicial" => "1071"
                        "paginaFinal" => "1080"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23855313"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack277918"
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0080" class="elsevierStylePara elsevierViewall">We would like to thank Dr&#46; Paola Bar&#243;n Rodiz&#44; of the radiology department of our hospital&#44; for her collaboration&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15782190/0000010700000007/v2_201704140340/S1578219016301366/v2_201704140340/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "34944"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "e- Case Report"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000007/v2_201704140340/S1578219016301366/v2_201704140340/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301366?idApp=UINPBA000044"
]
Compartir
Información de la revista
Vol. 107. Núm. 7.
Páginas e47-e51 (septiembre 2016)
Visitas
37301
Vol. 107. Núm. 7.
Páginas e47-e51 (septiembre 2016)
e-Casos clínicos
Acceso a texto completo
Mycoplasma pneumoniae-Induced Mucocutaneous Rash: A New Syndrome Distinct from Erythema Multiforme? Report of a New Case and Review of the Literature
Exantema mucocutáneo inducido por Mycoplasma pneumoniae: ¿un nuevo síndrome separado del eritema multiforme? Un nuevo caso y revisión de la literatura
Visitas
37301
M. Martínez-Pérez
Autor para correspondencia
mrcl_mtnez@yahoo.es

Corresponding author.
, A. Imbernón-Moya, A. Lobato-Berezo, M. Churruca-Grijelmo
Servicio de Dermatología y Venereología, Hospital Severo Ochoa, Madrid, Spain
Este artículo ha recibido
Información del artículo
Resumen
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Figuras (3)
Mostrar másMostrar menos
Tablas (1)
Table 1. Differences Between Mycoplasma-Induced Rash and Mucositis, Erythema Multiforme, and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Spectrum.
Abstract

Respiratory tract infection due to Mycoplasma pneumoniae can provoke cutaneous and mucosal rashes, which have been classified within the spectrum of erythema multiforme or Stevens-Johnson syndrome. This classification is of therapeutic and prognostic importance and has generated intense debate in the literature. A recent systematic review of 202 cases of mucocutaneous rashes associated with M. pneumoniae infection concluded that these rashes might constitute a distinct entity, for which the term Mycoplasma-induced rash and mucositis was proposed. We describe a patient with acute M pneumoniae respiratory tract infection who presented mucosal and cutaneous lesions that were difficult to classify as erythema multiforme or Stevens-Johnson syndrome; the lesions were compatible with the proposed new disease.

Keywords:
Mycoplasma pneumoniae
Erythema multiforme
Stevens-Johnson syndrome
Rash
Mucositis
Clinical classification
Treatment
Resumen

La infección respiratoria por Mycoplasma pneumoniae (MP) puede producir erupciones cutáneo-mucosas que se han considerado parte del espectro eritema multiforme o del síndrome de Stevens-Johnson. La clasificación de estas reacciones cutáneas, que tiene importancia pronóstica y terapéutica, ha generado mucha controversia en la literatura. Recientemente, una revisión sistemática de 202 casos de erupciones mucocutáneas asociadas a infección por MP concluye que pueden constituir una entidad distinta para la que se propone la expresión Mycoplasma-induced rash and mucositis. Presentamos un caso de infección respiratoria aguda por MP con lesiones mucosas y cutáneas difíciles de clasificar como eritema multiforme o síndrome de Stevens-Johnson, y cuyas características son compatibles con la nueva enfermedad propuesta.

Palabras clave:
Mycoplasma pneumoniae
Eritema multiforme
Síndrome de Stevens-Johnson
Exantema
Mucositis
Clasificación clínica
Tratamiento
Texto completo
Introduction

Mycoplasma pneumoniae infection affects the skin and mucosas in up to 25% of cases,1 and can cause erythema multiforme (EM)2 and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).3 The clinical overlap between these conditions, which has led to long-standing debate in the literature,4–9 makes diagnosis difficult in some cases.10,11 An extensive review of 202 cases of M pneumoniae-induced EM, SJS, and mucositis without rash was published recently.12 In their conclusions, the authors proposed a new entity which they called Mycoplasma-induced rash and mucositis. We present a case that we found difficult to classify and that was consistent with the new entity described. As suggested by those authors, we believe this entity could be helpful in the diagnosis and treatment of these cases in daily practice.

Case Description

The patient, a previously healthy 16-year-old girl, presented a 7-day history of fever of 38.5°C, odynophagia, cough, and wheeze. She was diagnosed with acute bronchitis and received treatment with inhaled budesonide and ibuprofen. She was subsequently seen for the rapid onset of lesions on the skin and mucosas. She had not received other drugs and she did not report a history of herpes infection.

Physical examination revealed intense stomatitis with confluent ulcers and scabs affecting all of the lips and the oral, palatine, and pharyngeal mucosas, associated with bilateral conjunctival hyperemia with discharge. Numerous irregular, edematous erythematous plaques with central vesicles and an erythematous halo, giving them the appearance of atypical target lesions, were observed on the skin of the face, trunk, limbs, perineum, and genital mucosa (Fig. 1). The palms and soles were not affected. No tonsillar exudate was observed and there were no palpable lymph nodes in the head and neck. Auscultation of the chest revealed crepitations. Abdominal examination was normal.

Figure 1.

A, Bilateral conjunctival hyperemia with discharge. B, Irregular, edematous erythematous papules with central vesicles and an erythematous halo, forming palpable atypical target lesions, widespread over the face, trunk, limbs, and perineal and genital mucosas, without affecting the palms and soles. C, Erosions, confluent ulcers, and scabs on the lips and mucosa. D, Changes in the skin lesions 2 days after onset of the rash. E, Detail of the atypical target lesions (corresponds to the area of the star in image B).

(0.34MB).

The patient was admitted with a clinical suspicion of erythema multiforme major secondary to M pneumoniae infection. Laboratory tests were as follows: C-reactive protein, 21mg/dL; anti-streptolysin O titer, 222U/mL; white cell count, 22850cells/μL (82.3% neutrophils, with no atypical lymphocytes); M pneumoniae IgM antibody, 292U; herpes simplex virus, Epstein-Barr virus, and cytomegalovirus serology, negative. Chest x-ray showed a pneumonia infiltrate in the right upper lobe (Fig. 2). Skin biopsy revealed an intense vacuolar interface lesion, isolated necrotic keratinocytes, and extensive dermoepidermal separation, with no epithelial necrosis (Fig. 3).

Figure 2.

Pneumonia infiltrate in the right upper lobe (arrow).

(0.09MB).
Figure 3.

Histopathology: extensive vacuolar interface lesion, isolated necrotic keratinocytes, and extensive dermoepidermal separation with no epithelial necrosis. Hematoxylin-eosin, original magnificationx10.

(0.24MB).

Treatment was started with intravenous methylprednisolone, 1mg/kg/d, clarithromycin, and acyclovir. The acyclovir was withdrawn after the serology results were received. Topical corticosteroids and antibiotics were applied to the conjunctival and oral mucosas, and fluid support and analgesia were administered until the patient's condition improved.

The skin lesions increased for a further 3 days, affecting up to 20% of the body surface, and took on a crusted, purpuric appearance, with lesions simultaneously observed in distinct stages. Some lesions developed flaccid blisters that did not coalesce or rupture. The Nikolski sign was negative and exfoliation did not occur. After 10 days the patient's condition had improved sufficiently for her to be discharged with only a residual hyperpigmentation.

Discussion

M pneumoniae is implicated in up to 40% of atypical pneumonias, particularly in children and young adults.1 It provokes changes in the skin in up to a fourth of patients, with nonspecific rash being most common, though stomatitis, vaginal ulcers, pityriasis rosea, Kawasaki disease, leukocytoclastic vasculitis, subcorneal pustular dermatosis, Sweet syndrome, thrombotic thrombocytopenic purpura, Raynaud disease, Henoch-Schonlein purpura, and other conditions are also observed.10 The exact incidence of EM in children and young adults who develop infection due to M pneumoniae and other Mycoplasma species13 is unknown, while that of SJS has been estimated at approximately 5%, though these data may be affected by the confusing nomenclature.10,11 Because of the clinical overlap between these syndromes, EM, SJS, and TEN have for decades been considered part of a spectrum. However, the Severe Cutaneous Adverse Reactions study concluded that EM and SJS/TEN can be separated into 2 distinct groups based on their clinical characteristics.5 A later multicenter study confirmed the validity of that classification and its correlation with etiologic and prognostic factors,8 and the 2 conditions are now considered separate entities.9 It was difficult to confidently classify our patient into 1 of these groups, because the infectious origin, the acute onset, the target morphology of the lesions, and the favorable clinical course supported a diagnosis of EM, while the general symptoms, the central distribution with centripetal spread, and the large area affected by the lesions, together with intense involvement of 3 mucosas, was consistent with SJS. The differences between these conditions are summarized in Table 1.

Table 1.

Differences Between Mycoplasma-Induced Rash and Mucositis, Erythema Multiforme, and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Spectrum.

  Epidemiology  Etiology  Basic Lesion  Distribution  Extension  Prognosis  Treatment 
M pneumoniae-induced rash and mucositis  Mean age=12 y12

Prodrome of respiratory tract infection 
M pneumoniae  Vesicles, blisters, mucositis (≥2 mucosas)  Variable
Predominantly acral 
Variable  Favorable

8% recurrence rate 
Macrolides 
EM  Mean age=25 y8

History of HSV infection 
46% HSV8 (5% drug-related)  Elevated typical/atypical target lesions  Acral  <10%  Favorable, 30% recurrence rate  Symptomatic

Consider HSV suppression 
SJS spectrum  Mean age=45 y8

Drug exposure
45% drug-related8

Other diseases (collagen disease, HIV, tumors, 15% HSV)
Flat atypical target lesions

Blisters arising on macules and patches
Trunk<10%  4%a  Withdrawal of the causative drugs

Supportive measures 
SJS/TEN  10-30%  7%a   
TEN  >30%  40%a   

Abbreviations: EM, erythema multiforme; HSV, herpes simplex virus; SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis.

a

Mortality.

In a study recently published by Canavan et al.,12 the authors reviewed the epidemiological and clinical characteristics of the 202 published cases of mucocutaneous rash associated with M pneumoniae. Their results, which we summarize here, led them to propose the creation of a new entity separate from the EM spectrum. Their patients were young (mean age, 11.9 years), with prodromal symptoms consisting of cough, malaise, and fever the week prior to the skin rash. The distribution of the lesions was acral in 46%, widespread in 31%, and on the trunk in 23%; lesion morphology was variable, the most common forms being vesicles and blisters (77%) and target lesions (48%). Mucosal involvement was intense and was fundamental to the diagnosis. Most common was oral mucositis, which occurred in 94% of cases, followed by bilateral purulent conjunctivitis (82%) and involvement of the urogenital mucosa (63%). The mean number of mucosas affected was 2.5. The disease had a benign course in the majority of patients, with complete recovery in 81%. Only 4% of patients required management in an intensive care unit according to that review article, and the estimated mortality was 3%. Patients were mainly treated with antibiotics (80%) and systemic corticosteroids (35%); a minority (8%) received intravenous immunoglobulin. Recurrence rates were not particularly high (8%). Those authors concluded that the etiology, lesion morphology, and clinical course, as well as the potentially distinct treatment of these patients, justified the designation of a clinical entity distinct from classic herpes simplex virus-associated EM and from drug-induced SJS/TEN. They proposed the term Mycoplasma-induced rash and mucositis (MIRM). This new classification is particularly useful in cases of extensive mucositis due to M pneumoniae without skin rash (MIRM sine rash for those authors), which did not adapt to the previous classifications and which could be due to certain strains of M pneumoniae.

The etiologic and pathogenic hypothesis is that MIRM is caused by the production of immunoglobulins by proliferating clones of B cells, and that this leads to immune complex deposition in the skin and to the activation of complement. This also differentiates the condition from EM and from SJS/TEN, which are caused by a type IV delayed hypersensitivity reaction and by Fas-ligand-mediated cytotoxicity.

Conclusion

Our case is compatible with those described by Canavan et al., and its classification within this new entity would dispel the diagnostic doubts that persisted after applying the criteria of the Severe Cutaneous Adverse Reactions study. We would therefore favor accepting the proposal of those authors.

The classification of the severe mucocutaneous diseases secondary to infections and drugs is complex due to the clinical overlap between them. After decades of controversy, EM was separated from SJS/TEN in 2002.8 Likewise, in 2013, drug reaction with eosinophilia and systemic symptoms (DRESS) was separated from the SJS spectrum.14 Acceptance of MIRM as an independent entity could facilitate correct diagnosis and more adequate treatment of our patients.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this research.

Confidentiality of data

The authors declare that they followed their hospital's regulations regarding the publication of patient information.

Right to privacy and informed consent

The authors declare that no private patient data are disclosed in this article.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

We would like to thank Dr. Paola Barón Rodiz, of the radiology department of our hospital, for her collaboration.

References
[1]
P.C. Schalock, J.B. Brennick, J.G. Dinulos.
Mycoplasma pneumoniae infection associated with bullous erythema multiforme.
J Am Acad Dermatol, 52 (2005), pp. 705-706
[2]
M. Grosber, M. Alexandre, E. Poszepczynska-Guigne, J. Revuz, J.C. Roujeau.
Recurrent erythema multiforme in association with recurrent Mycoplasma pneumoniae infections.
J Am Acad Dermatol, 56 (2007), pp. S118-S119
[3]
Y.K. Tay, J.C. Huff, W.L. Weston.
Mycoplasma pneumoniae infection is associated with Stevens-Johnson syndrome, not erythema multiforme (von Hebra).
JAAD, 35 (1996), pp. 757-760
[4]
J.C. Roujeau.
What is going on in erythema multiforme?.
Dermatology, 188 (1994), pp. 249-250
[5]
S. Bastuji-Garin, B. Rzany, R.S. Stern, N.H. Shear, L. Naldi, J.C. Roujeau.
Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome and erythema multiforme.
Arch Dermatol, 129 (1993), pp. 92-96
[6]
J.C. Roujeau.
The spectrum of Stevens-Johnson syndrome and toxic epidermal necrolysis: A clinical classification.
J Investigative Dermat, 102 (1994), pp. 28-30
[7]
H. Assier, S. Bastuji-garin, J. Revuz, J.C. Roujeau.
Erythema multiforme with mucous membrane involvement and Stevens-Johnson syndrome are clinically different disorders with distinct causes.
Arch Dermatol, 131 (1995), pp. 539-543
[8]
A. Auquier_Dunant, M. Mockenhaupt, L. Naldi, O. Correia, W. Schröder, J.C. Roujeau.
Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome and toxic epidermal necrolysis: Results of an international prospective study.
Arch Dermatol, 138 (2002), pp. 1019-1024
[9]
C. Laguna, B. Martín, A. Torrijos, M.L. García-Melgares, I. Febrer.
Síndrome de Stevens-Johnson y necrólisis epidérmica tóxica: experiencia clínica y revisión de la literatura especializada.
Actas Dermosifiliogr, 97 (2006), pp. 177-185
[10]
C. Leauté-Labreze, T. Lamireau, D. Chawki, J. Maleville, A. Taïeb.
Diagnosis, classification and management of erythema multiforme and Stevens-Johnson syndrome.
Arch Dis Child, 83 (2000), pp. 347-352
[11]
P.C. Schalock, J.G.H. Dinulos, N. Pace, K. Schwarzenberger, J.K. Wenger.
Erythema multiforme due to Mycoplasma pneumoniae infection in two children.
Pediatr Dermatol, 23 (2006), pp. 546-555
[12]
T.N. Canavan, E.F. Mathes, I. Frieden, K. Shinkai.
Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme. A systematic review.
J Am Acad Dermatol, 72 (2015), pp. 239-245
[13]
T. Toledo-Pastrana, A. Zapata-López, A. Michán-Doña.
Exudado uretral y afectación mucocutánea.
Rev Clin Esp, 214 (2014), pp. e91-e92
[14]
S.H. Kardaun, P. Sekula, L. Valeyrie-Allanore, Y. Liss, C.Y. Chu, D. Creamer, et al.
Drug reaction with eosinophilia and systemic symptoms (DRESS): An original multisystem adverse drug reaction; results from the prospective RegiSCAR study.
Br J Dermatol, 169 (2013), pp. 1071-1080

Please cite this article as: Martínez-Pérez M, Imbernón-Moya A, Lobato-Berezo A, Churruca-Grijelmo M. Exantema mucocutáneo inducido por Mycoplasma pneumoniae: ¿un nuevo síndrome separado del eritema multiforme? Un nuevo caso y revisión de la literatura. Actas Dermosifiliogr. 2016;107:e47–e51.

Copyright © 2016. Elsevier España, S.L.U. and AEDV
Descargar PDF
Idiomas
Actas Dermo-Sifiliográficas
Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?