{
  "abstract": "An early adolescent male, firstborn to non-consanguineous parents, presented with a 7-day history of fever, accompanied by cough and rhinorrhoea for 6 days, and the onset of oral ulcers over the preceding 3 days. The patient has a history of asthma and moderate-to-severe persistent allergic rhinitis, for which he is not receiving regular intranasal or inhaled corticosteroid therapy. His immunisations were up to date according to the national immunisation schedule. On initial examination, the patient was febrile (temperature: 101°F) with stable vital signs. There was no evidence of pallor, clubbing, cyanosis or lymphadenopathy. Notably, aphthous ulcers were observed in the oral cavity. Systemic examination revealed crepitations localised to the right interscapular and infrascapular regions; examination of other systems was unremarkable. The child was admitted with a provisional diagnosis of lower respiratory tract infection. A chest radiograph demonstrated right lower zone infiltrates ( figure 1). Laboratory investigations revealed a haemoglobin level of 13.5 g/dL, total leucocyte count of 9800 cells/mm³ (neutrophils 57%, lymphocytes 25%) and platelet count of 4 53 000/mm³. The erythrocyte sedimentation rate was elevated at 52 mm/hour, and C-reactive protein was markedly raised at 18.6 mg/dL (reference: <0.8 mg/dL). Infectious workup, including serology for dengue, malaria, typhoid, scrub typhus and leptospirosis, as well as blood and urine cultures, yielded negative results. Empiric therapy with intravenous ceftriaxone and nebulisation was initiated. On the third day of admission, the patient exhibited progression of oral lesions, including eschar formation involving the lips and aphthous ulcers of the tongue (figure 2). Skin involvement was minimal, limited to a maculopapular rash over the anterior abdominal wall (figure 3), and the patient continued to experience fever spikes. At this juncture, the differential diagnosis considered included herpes simplex virus infection (ruled out due to eschar of lips and absence of other skin lesions), oral candidiasis (excluded by the absence of whitish plaques and the presence of eschar of lips) and Stevens-Johnson syndrome (SJS). However, SJS was considered less likely given the predominant oral mucosal involvement with minimal cutaneous findings. Toxic epidermal necrolysis (TEN) was excluded in the absence of significant skin involvement. The distinction between SJS and TEN was further clarified by the extent of skin involvement: <30% in SJS and >30% in TEN. Given the clinical presentation of eschar of lips, predominant oral involvement, minimal skin lesions and features of lower respiratory tract infection, Mycoplasma pneumoniae infection was suspected, and serological testing was pursued. The patient was commenced on doxycycline and low-dose oral corticosteroids. The choice of doxycycline was guided by regional patterns of azithromycin-resistant Mycoplasma and the patient’s prior exposure to azithromycin for 5 days before admission. Following initiation of this regimen, the patient demonstrated rapid clinical improvement, with resolution of fever, healing of oral and cutaneous lesions and normalisation of appetite. Mycoplasma pneumoniae IgM serology returned positive (23; >10 considered positive), confirming the diagnosis of Mycoplasma-induced rash and mucositis (MIRM). The patient was discharged in stable condition with advice for regular follow-up.",
  "authors": [
    {
      "affiliations": [
        "Department of Pediatrics, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India"
      ],
      "name": "Vinoth Ponnurangam"
    },
    {
      "affiliations": [
        "Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India"
      ],
      "name": "Venkatesh Kumar Balan"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India"
      ],
      "name": "Sruthi Balan"
    },
    {
      "affiliations": [
        "Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India"
      ],
      "name": "Rajesh Balan"
    }
  ],
  "title": "Mycoplasma-induced rash and mucositis (MIRM) in an adolescent boy",
  "uid": "2605a44a-0355-502d-bf52-05da441fa42b"
}