Mycoplasma Pneumoniae-Induced Rash and Mucositis: A Systematic Review of the Literature

INTRODUCTION: Mycoplasma pneumoniae (MP) is a common respiratory pathogen that can result in community-acquired pneumonia (CAP). Approximately 25% of patients diagnosed with MP experience extrapulmonary manifestations. Mycoplasma-induced rash and mucositis (MIRM) was coined as a unique disease process in 2014. MIRM has prominent mucositis with or without a characteristic vesiculobullous and/or atypical targetoid eruption. Appropriate identification of this disease is important because it has a milder disease course with low rates of sequelae, and lower mortality compared to Stevens-Johnson syndrome, erythema multiforme, and toxic epidermal necrolysis. The objective of this systematic review was to examine the English literature on Mycoplasma Pneumonia-induced rash and mucositis since the establishment of its diagnosis in 2014. METHODS: The following online databases were used to identify appropriate studies that met the established inclusion and exclusion criteria: Pubmed, Cochrane, MedLine, Health Evidence, EPPI center, Allied Health Evidence. The following MesH search terms were used to further identify articles; “Mycoplasma pneumoniae induced rash and mucositis,” “Mycoplasma pneumoniae rash and mucositis,” “Mycoplasma pneumoniae rash,” “Mycoplasma pneumoniae mucositis,” “MIRM,” “Mycoplasma induced rash and mucositis,” “Mycoplasma rash and mucositis,” “Mycoplasma rash,” and “Mycoplasma mucositis.” Data was extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: One hundred and seventy-five records were initially screened, and nineteen studies were included in the review, leading to a total of 27 patients. Patients had a mean age of 16 years old (Range 4 - 46 years old), with the majority being males (74%). Pulmonary symptoms tended to precede extrapulmonary symptoms on an average of 7.8 days. Extrapulmonary symptoms consisted of oral lesions (96.3%) followed by ocular lesions (92.6%) and genital lesions (59.3%). Female patients were more likely to have genital lesions (71.4%) when compared with male patients (55%). Cutaneous rashes occurred in approximately one-half of the patients, which supports the theory that MIRM is a separate clinical entity from SJS and other related skin disorders. Confirmatory testing for MIRM was performed using IgM/IgG Mycoplasma antibody testing or PCR in 19 (66.7%) and 6 (22.2%) patients respectively, although four cases reported the use of both serology and PCR, while five did not report confirmatory testing. Systemic antibiotics were used frequently in treatment 22 patients (77.8%) and 27 (100%) of the patients received various supportive care. Approximately 11 (37%) patients of reported cases used systemic steroids to reduce systemic inflammation. Other systemic treatments were used in six (21.4%) cases, and included intravenous immunoglobulins and cyclosporine A. Only eight patients (22.2%) reported having any lasting sequelae. CONCLUSION: Mycoplasma-induced rash and mucositis is a recently described extra-pulmonary manifestation of Mycoplasma pneumoniae infections. To the best of the authors’ knowledge, this is the first systematic review of the MIRM literature since the introduction of the diagnosis in 2014. The authors hope that this review can serve to better our current understanding and lead to improved identification, work-up, and treatment of this disease. One notable limitation of this study is the relatively small sample size, which is due to the recent introduction of the term.