Erythema Multiforme Case Study
TITLE: Could this be multicausal Erythema Multiforme? A Case report of Erythema Multiforme Major after recent antibiotic use in a patient positive for HIV, HSV and Mycoplasma Pneumonia.
AUTHOR ORDER: Merjona Saliaj, MD, Nikola Tankosic, MD, Vimala Ramasamy, MD
INTRODUCTION
Erythema Multiforme (EM) major is a type IV hypersensitivity immune reaction which can present with various skin lesions such as macules, papules, plaques and may also involve mucosa. Underlying etiology usually is unknown, however it is often related to a drug (sulfa and penicillin) or an infection [Herpes Simplex Virus (HSV) and Mycoplasma pneumonia (M. pneumonia)]. Seventy percent of EM major are found to be Herpes Associated Erythema multiforme (HAEM).
CASE DESCRIPTION
A 63 year old female with history of HIV (15 years ago, compliant with antiretroviral therapy (ART), CD4 count of 600 and that her viral load was undetectable) presented with lower abdominal pain and was treated with Ciprofloxacin and Flagyl for possible diverticulitis. Two days later, her abdominal pain improved, however she developed odynophagia, mucosal lesions and rash. Her rashes were crusted and papule-like over the trunk and scattered …show more content…
erythematous papules on the extremities and palms. Immediately her antibiotics were stopped and patient was started on oral prednisone 40 mg for 4 days. Eventually, her rash improved, however she developed oral sores, odynophagia, ocular itching, crusting, without genital involvement. She also endorsed chronic cough with increased productive sputum however she had a smoking history of 44 pack years.
Patient tested positive for HSV 1 DNA and HSV II IgG and negative for Herpes HSV I IgG-EIA. She also tested positive for M. pneumonia IgM, however there was no evidence of lung involvement clinically, radiographically or on physical examination. Eventually, her skin punch biopsy on the left arm suggested resolving EM.
DISCUSSION
Major differentials in our case included EM major, Stevens Johnson Syndrome, underlying infection (M.
pneumonia, CMV, HSV), or paraneoplastic pemphigus. EM major is an immune reaction noticed 1-2 weeks after starting a drug, or within 48 hours after a recurrent exposure. In our patient, her HSV cultures were positive only in samples collected from the eye and not the oral samples, which could be explained from the fact that HSV-1 viral shedding usually occurs between 48-60 hours from the onset of herpes labialis symptoms and are undetectable beyond 96 hours of symptom onset. Fifty percent of EM cases occur in the age group of 20-40 years (50% of cases <20 and males) or immunocompromised individuals. Given her recent CD4 count and viral load, our patient was not
immunecompromised.
CONCLUSION
In our case, EM major was diagnosed based on her clinical presentation, thorough history taking and laboratory results. Although it seemed her initial presentation was triggered likely from ciprofloxacin, it seems to be a case of multiple crops of EM major including HSV and M. pneumonia. Providers continue to find it challenging to differentiate the causes of EM as it proved to be with this patient.
AUTHOR ORDER: Merjona Saliaj, MD, Nikola Tankosic, MD, Vimala Ramasamy, MD
INTRODUCTION
Erythema Multiforme (EM) major is a type IV hypersensitivity immune reaction which can present with various skin lesions such as macules, papules, plaques and may also involve mucosa. Underlying etiology usually is unknown, however it is often related to a drug (sulfa and penicillin) or an infection [Herpes Simplex Virus (HSV) and Mycoplasma pneumonia (M. pneumonia)]. Seventy percent of EM major are found to be Herpes Associated Erythema multiforme (HAEM).
CASE DESCRIPTION
A 63 year old female with history of HIV (15 years ago, compliant with antiretroviral therapy (ART), CD4 count of 600 and that her viral load was undetectable) presented with lower abdominal pain and was treated with Ciprofloxacin and Flagyl for possible diverticulitis. Two days later, her abdominal pain improved, however she developed odynophagia, mucosal lesions and rash. Her rashes were crusted and papule-like over the trunk and scattered …show more content…
erythematous papules on the extremities and palms. Immediately her antibiotics were stopped and patient was started on oral prednisone 40 mg for 4 days. Eventually, her rash improved, however she developed oral sores, odynophagia, ocular itching, crusting, without genital involvement. She also endorsed chronic cough with increased productive sputum however she had a smoking history of 44 pack years.
Patient tested positive for HSV 1 DNA and HSV II IgG and negative for Herpes HSV I IgG-EIA. She also tested positive for M. pneumonia IgM, however there was no evidence of lung involvement clinically, radiographically or on physical examination. Eventually, her skin punch biopsy on the left arm suggested resolving EM.
DISCUSSION
Major differentials in our case included EM major, Stevens Johnson Syndrome, underlying infection (M.
pneumonia, CMV, HSV), or paraneoplastic pemphigus. EM major is an immune reaction noticed 1-2 weeks after starting a drug, or within 48 hours after a recurrent exposure. In our patient, her HSV cultures were positive only in samples collected from the eye and not the oral samples, which could be explained from the fact that HSV-1 viral shedding usually occurs between 48-60 hours from the onset of herpes labialis symptoms and are undetectable beyond 96 hours of symptom onset. Fifty percent of EM cases occur in the age group of 20-40 years (50% of cases <20 and males) or immunocompromised individuals. Given her recent CD4 count and viral load, our patient was not
immunecompromised.
CONCLUSION
In our case, EM major was diagnosed based on her clinical presentation, thorough history taking and laboratory results. Although it seemed her initial presentation was triggered likely from ciprofloxacin, it seems to be a case of multiple crops of EM major including HSV and M. pneumonia. Providers continue to find it challenging to differentiate the causes of EM as it proved to be with this patient.