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As COVID-19, caused by SARS-CoV-2, spreads worldwide, various patterns of associated dermatologic diseases continue to emerge. Early reports classified multiple cutaneous manifestations of SARS-CoV-2 infection.1 In this article, we report the observation of a newly associated mucocutaneous eruption in a pediatric patient with confirmed SARS-CoV-2 infection.
Report of a Case
A previously healthy 17-year-old male presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved. At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive. He denied fever, cough, dyspnea, rhinorrhea, and gastrointestinal symptoms at any time. Although he had taken acetaminophen and ibuprofen before presenting to the emergency department, he took no medications before the onset of his mucocutaneous eruption.
At initial presentation, the patient did not have a fever and was in no distress. His vital signs were normal, including a respiratory rate of 16 breaths per minute and an oxygen saturation of 97%. Physical examination revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and 5 small vesicles on the trunk and upper extremities (Figure 1). The remainder of the mucocutaneous (including palms and soles), cervical lymphatic, and cardiopulmonary examinations were unremarkable. Laboratory testing results revealed a normal white blood cell count (7030 leukocytes/μL [to convert to ×109/L, multiply by 0.001]; reference: 5240-9740 leukocytes/μL) with mild absolute lymphopenia (930 lymphocytes/μL; reference: 1030-2180), slightly elevated creatinine level (1.2 mg/dL [to convert to μmol/L, multiply by 88.4]; reference: 0.3-1.0 mg/dL), normal liver function, slightly elevated C-reactive protein level (3.0 mg/dL [to convert to mg/L, multiply by 10]; reference: <0.5 mg/dL), normal D-dimer level (0.37 μg/mL [to convert to nmol/L, multiply by 5.476]; reference: <0.5 mg/dL), and normal ferritin level (180 ng/mL [to convert to μg/L, multiply by 1]; reference: 10-320 μg/L). Microbiological testing results revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. Titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated. A diagnosis of SARS-CoV-2–associated reactive infectious mucocutaneous eruption (RIME) was made.
A, Shallow erosions of the vermilion lips and hard palate. B, Periurethral erythema and shallow erosions on the glans penis. C, Few small vesicles on the upper extremities.
The patient was prescribed betamethasone valerate, 0.1%, ointment for the lips and penis, intraoral dexamethasone solution, viscous lidocaine, acetaminophen, and ibuprofen. However, he noted progressively worsening oral pain over the subsequent 3 days, prompting initiation of oral prednisone, 60 mg (approximately 1 mg/kg), daily for 4 consecutive days (Figure 2A). This was followed by drastic improvement in his mucositis (Figure 2B). He did have brief recurrence of oral mucositis 3 months later, but this also resolved quickly with prednisone, 80 mg, for 6 days.
A, The patient experienced worsening mucositis and pain 10 days after initial anosmia and ageusia, at which time prednisone treatment was initiated. B, The mucositis had essentially resolved on follow-up 3 weeks after starting prednisone.
Formerly known as Mycoplasma-induced rash and mucositis, RIME has arisen as the preferred terminology to include mucocutaneous eruptions that are caused by other infectious agents.2 This case describes RIME secondary to SARS-CoV-2 infection, details its resolution with systemic steroids, and notes the potential for recurrence with subsequent milder symptoms, as has been previously reported.3 The combination of anosmia and ageusia, multiple positive SARS-CoV-2 PCR tests, and no other identified contemporaneous infections (the elevated Mycoplasma pneumoniae IgG titer with low IgM titer and negative nasopharyngeal PCR likely indicated prior exposure) suggests SARS-CoV-2 as the infectious trigger. The sparse cutaneous involvement and lack of dusky targetoid lesions also distinguish RIME from Stevens-Johnson syndrome and erythema multiforme (which has been described in association with SARS-CoV-2 infection).4,5 Furthermore, RIME can be distinguished from the newly described multisystem inflammatory syndrome in children, which is associated with Kawasaki disease–like features, including mucocutaneous involvement, systemic symptoms, and dramatically elevated systemic inflammatory markers.6 This case highlights what is to our knowledge the first report of SARS-CoV-2–induced RIME and distinguishes this entity from other mucocutaneous eruptions with substantially different prognoses and treatment algorithms.
Corresponding Author: Zachary E. Holcomb, MD, Dermatology Program, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (email@example.com).
Published Online: April 7, 2021. doi:10.1001/jamadermatol.2021.0385
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient’s mother for granting permission to publish this information.
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Holcomb ZE, Hussain S, Huang JT, Delano S. Reactive Infectious Mucocutaneous Eruption Associated With SARS-CoV-2 Infection. JAMA Dermatol. 2021;157(5):603–605. doi:10.1001/jamadermatol.2021.0385
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