Boy with fever, cough, and oral lesions

July 1, 2016

By J David Sterns, MD
Riva Kamat, MD, FAAP

Article

A previously healthy, 16-year-old Hispanic boy initially presents to the clinic with a 5-day history of tactile fevers, achy malaise, congestion, and a dry cough. He was afebrile with negative rapid strep and monospot tests, but was prescribed fluticasone, benzonatate, and ibuprofen for a presumed upper respiratory infection. He was encouraged to return if symptoms did not improve.

The Case

At home, the patient's cough persisted with the addition of several episodes of nonbloody, nonbilious posttussive emesis. On day 9 of illness, he developed oral vesicular lesions associated with discomfort when swallowing solid foods, prompting a visit to the local emergency department (ED). There, his temperature was 102.92°F, but physical exam and chest imaging performed at that time were reassuring for a safe discharge home with close follow-up after being given a 5-day course of azithromycin for bronchitis (Figure 1).

By day 12 of his illness, the patient’s course was worsening. The vesicular oral lesions were friable and beginning to bleed. His coughing episodes were increasingly frequent and produced blood-streaked sputum. Severe odynophagia prevented him from consuming both solids and liquids. A complete physical exam by his pediatrician at follow-up revealed red, round, ulcerative lesions of the ventral penile shaft along with skin peeling and scant mucus discharge at the urethral opening. Because of his poor fluid intake and progressing symptomatology, he was quickly referred back to the ED and admitted for continued evaluation and management (Figure 2).

NEXT: Patient History

History

The patient endorsed a history of acne vulgaris for which he took minocycline daily. There was, however, no prior history of surgeries, abnormal development, or variations from a regular healthy diet. Family history was significant only for maternal allergic reaction of unknown severity to Percocet (oxycodone hydrochloride with acetaminophen) and Motrin (ibuprofen). The patient had no known drug allergy prior to presentation, and his immunizations were up-to-date.

Upon HEADDSSS (Home, Education, Activities, Drug use and abuse, Death, Sexual behavior, Suicidality and depression, Safety) assessment, the boy stated that he lives at home with his mother, father, and 2 younger sisters, the oldest of which was recently diagnosed with pneumonia and successfully treated with azithromycin. He denied having pets in the home. He was in the 11th grade and doing well academically. Daily physical activity was limited because he was not interested in sports but rather enthusiastically committed to playing video games. He denied illicit substance use, depressive symptoms, safety concerns, sexual activity of any kind, or suicidal ideation.

Physical exam

Upon physical examination, the patient was afebrile with normal vital signs. He appeared uncomfortable, tired, and in mild distress. His eyes were without discharge or conjunctival injection. External ear canals were normal. Nares revealed hemorrhagic crusts. Friable, ulcerative lesions and dried blood were found on his lips; the superficial buccal mucosa was sloughing and actively bleeding; the surface of his tongue was covered by white ulcerations posteriorly; the palate and posterior oropharynx were erythematous and edematous; and tonsillar exudates were appreciated bilaterally. Lung exam was somewhat limited by dry coughing upon deep inspiration, but rales were appreciated bilaterally in the lower lung fields. Mild erythema of the urethral opening along with a single ulcerative lesion of the ventral penile shaft was found. The remainder of his physical exam, including a thorough skin examination, was normal.

Differential diagnosis

Taking into account the patient’s presenting history and physical exam findings, the team proposed a fairly wide differential (Table). Included in the list were an atypical presentation of the autoimmune mechanisms underlying Crohn disease, absent of any associated gastrointestinal manifestations, and Behçet disease, without its characteristic ulcerative and erythematous nodules or anterior uveitis. Ingestion of a corrosive agent that might precipitate the mucocutaneous oral findings also was considered, although certainly the patient’s age and absence of any intention for self-harm made this possibility less likely.

Infectious etiologies were postulated as well, including herpangina of an enterovirus infection or herpes simplex mucositis, most commonly seen as a reactivation event of a prior primary infection in immunocompromised patients. Even a severe drug reaction to ibuprofen, such as Stevens-Johnson syndrome (SJS), was introduced as a possibility, although the limited involvement of his pathology to the nasal-oral and genital areas lessened the team’s concern (Figure 6).

In narrowing the differential, patient demographics such as age and gender, benign past medical history, absence of high-risk sexual or self-harm behavior, and context of presentation with corresponding respiratory symptoms, fever, and limited cutaneous findings led the team to favor an infectious etiology. What remained to be determined was the causative organism and the extent of the pathology it would instigate in the patient.

NEXT: Differential diagnosis and Diagnostic approach

NEXT: Further testing and discussion

Further testing

Overnight, ibuprofen was discontinued for concerns of SJS and empiric acyclovir was started for suspected primary herpes simplex virus (HSV) infection. A complete blood count with manual differential and complete metabolic panel were normal. A urinalysis showed scant leukocyte esterase and 5 to 10 white blood cell counts, but no red blood cells. Serum cultures, bacterial genital cultures, HSV-1 and HSV-2 polymerase chain reaction tests, culture swabs of the oral and genital lesions, and Neisseria gonorrhoeae and Chlamydia trachomatis RNA urine tests all were sent, none of which returned positive. Chest x-ray was repeated and was significant for subtle right lower lobe infiltrates.

More: Muscositis and rash in a 9-year-old boy

Because initial workup in the community hospital failed to provide an identifiable etiology for the patient’s clinical course, he was transferred to the nearest pediatric tertiary care center where he was found to have Mycoplasma-induced rash and mucositis, also known as MIRM.

Treatment and outcome

With suspicion for MIRM secondary to inadequately treated M pneumoniae pneumonia, the patient was started on a second 5-day course of azithromycin along with IV maintenance fluids and supportive care for the oral lesions. Famotidine was begun for prophylactic treatment of presumed gastrointestinal mucositis. As mentioned previously, a telemedicine dermatology consult was utilized to help confirm the suspected diagnosis, and a 5-day course of prednisone was initiated. Mycoplasma IgG and IgM serology were ordered and returned positive after hospital discharge on his 16th day of illness. During a follow-up phone call with the mother, she noted significant improvement in his symptoms with normal oral intake and a successful return to school 3 days after leaving the hospital (Figure 7).

NEXT: Further discussion

Dr Sterns is a pediatric intern at Naval Medical Center, San Diego, California. Dr Kamat is a pediatric hospitalist, Inova Children’s Hospital, Falls Church, Virginia. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.