Mucocutaneous Manifestations of Mycoplasma pneumoniae Infection: Case Reports of SJS, MIRM, and Fuchs Syndrome
DOI:
https://doi.org/10.24079/CAJMS.2025.04.007Keywords:
Mycoplasma pneumoniae, extrapulmonary, mucositis, Stevens–Johnson syndrome, Mycoplasma-induced rash with mucositisAbstract
Objective: After lifting COVID-19 restrictions, increased spread of Mycoplasma pneumoniae has been observed in both adults and children, with a growing number of cases showing extrapulmonary involvement. We present reports of three cases: pneumonia with infection-related Stevens–Johnson syndrome affecting 7-8% of body surface area and leading to pulmonary obstruction in a child; pneumonia with rash and severe mucositis in an adolescent; and Fuchs syndrome in an adult. We further discuss the pathogenesis of extrapulmonary manifestations, focusing on the role of the CARDS exotoxin and host immune responses.
Downloads
23
References
1. Kuitunen I, Artama M, Haapanen M, et al. Rhinovirus spread in children during the COVID-19 pandemic despite social restrictions – A nationwide register study in Finland. J Med Virol. 2021;93:6063–6067. https://doi.org/10.1002/jmv.27180
2. Haapanen M, Renko M, Artama M, Kuitunen I, et al. The impact of the lockdown and the re-opening of schools and day cares on the epidemiology of SARS-CoV-2 and other respiratory infections in children a nationwide register study in Finland. EClinicalMedicine. 2001;34:100807. https://doi.org/10.1016/j.eclinm.2021.100807
3. Poole S, Brendish N J, Tanner A R, et al. Physical distancing in schools for SARS-CoV-2 and the resurgence of rhinovirus. Lancet Respir Med. 2020;8:92. https://doi.org/10.1016/S2213-2600(20)30502-6
4. Lomholt FK, Emborg H D, Nørgaard S K, et al. Resurgence of respiratory syncytial virus in the summer of 2021 in Denmark a large out-of-season epidemic affecting older children. Open Forum Infect Dis. 2024;11(3):ofae069. https://doi.org/10.1093/ofid/ofae069
5. Silva-Costa C, Gomes-Silva J, Pinho M, et al. Rebound of pediatric invasive pneumococcal disease in Portugal after the COVID-19 pandemic was not associated with significant serotype changes. J Infect. 2024;89:106242. https://doi.org/10.1016/j.jinf.2024.106242
6. Rybak A, Assad Z, Levy C, et al. Age-specific resurgence in invasive pneumococcal disease incidence in the COVID-19 pandemic era and its association with respiratory virus and pneumococcal carriage dynamics: A time-series analysis. Clin Infect Dis. 2024;78(4):855–859. https://doi.org/10.1093/cid/ciad746
7. Dungu K H S, Holm M, Hartling U, et al. Mycoplasma pneumoniae incidence, phenotype, and severity in children and adolescents in Denmark before, during, and after the COVID-19 pandemic: a nationwide multicentre population-based cohort study. Lancet Reg Health Eur. 2024;47:101103. https://doi.org/10.1016/j.lanepe.2024.101103
8. Meyer Sauteur P M, Beeton M L, Uldum S A, et al. Mycoplasma pneumoniae detections before and during the COVID-19 pandemic: results of a global survey, 2017 to 2021. Euro Surveill. 2022;27:100746. https://doi.org/10.2807/1560-7917ES.2022.27.19.2100746
9. Meyer Sauteur P M, Chalker V J, Berger, et al. Mycoplasma pneumoniae beyond the COVID-19 pandemic: where is it? Lancet Microbe. 2022;3(12):e897. https://doi.org/10.1016/S2666-5247(22)00190-2
10. Meyer Sauteur P M, Beeton M L, European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycoplasma and Chlamydia Infections (ESGMAC), ESGMAC Mycoplasma pneumoniae Surveillance (MAPS) study group. Mycoplasma pneumoniae: delayed re-emergence after COVID-19 pandemic restrictions. Lancet Microbe. 2024;5(2):e100-e101. https://doi.org/10.1016/S2666-5247(23)00344-0
11. Robinson E, Zellner M, Osuna E, et al. Evolving clinical features of Mycoplasma pneumoniae infections following COVID-19 pandemic restrictions: a retrospective, comparative cohort study. Eur J Pediatr. 2025;184:535. https://doi.org/10.1007/s00431-025-06326-y
12. Lofgren D, Lenkeit C. Mycoplasma pneumoniae-induced rash and mucositis: a systematic review of the literature. Spartan Med Res J. 2021;6:25284. https://doi.org/10.51894/001c.25284
13. Narita M. Classification of extrapulmonary manifestations due to Mycoplasma pneumoniae infection on the basis of possible pathogenesis. Front Microbiol. 2016;7: 23. https://doi.org/10.3389/fmicb.2016.00023
14. Kannan T R, Baseman JB. ADP-ribosylating and vacuolating cytotoxin of Mycoplasma pneumoniae represents unique virulence determinant among bacterial pathogens. Proc Natl Acad Sci USA. 2006;103(17):6724-6729. https://doi.org/10.1073/pnas.0510644103
15. Kannan T R, Provenzano D, Wright J R, et al. Identification and characterization of human surfactant protein A binding protein of Mycoplasma pneumoniae. Infect Immun. 2005;73(5):2828-2834. https://doi.org/10.1128/IAI.73.5.2828-2834.2005
16. Hahn D L, Schure A, Patel K, Childs, et al. Chlamydia pneumoniae-specific IgE is prevalent in asthma and is associated with disease severity. PLoS One. 2012;7: e35945.https://doi.org/10.1371/journal.pone.0035945
17. Johnston S L, Martin R J, et al. Chlamydophila pneumoniae and Mycoplasma pneumoniae: a role in asthma pathogenesis? Am J Respir Crit Care Med. 2005;172: 1078–1089. https://doi.org/10.1164/rccm.200412-1743PP
18. Iannuzo N, Insel M, Marshall C, et al. CC16 deficiency in the context of early-life Mycoplasma pneumoniae infection results in augmented airway responses in adult mice. Infect Immun. 2022;90:e0054821. https://doi.org/10.1128/iai.00548-21
19. Ko H M, Choi S H, Jee W, et al. Rosa laevigata attenuates allergic asthma exacerbated by water-soluble PM by downregulating the MAPK pathway. Front Pharmacol. 2022;13:925502. https://doi.org/10.3389/fphar.2022.925502
20. Lopez-Campos J L, Miravitlles M, de la Rosa CD, et al. Current challenges in chronic bronchial infection in patients with chronic obstructive pulmonary disease. J Clin Med. 2020;9:1639. https://doi.org/10.3390/jcm9061639
21. Zhong H, Yin R, Zhao R, et al. Analysis of clinical characteristics and risk factors of plastic bronchitis in children with Mycoplasma pneumoniae pneumonia. Front Pediatr. 2021;9:735093.https://doi.org/10.3389/fped.2021.735093
22. Bose S, Segovia JA, Somarajan SR et al. 2014. ADP-ribosylation of NLRP3 by Mycoplasma pneumoniae CARDS toxin regulates inflammasome activity. MBio 5, 2014;5(6):e02186-14. https://doi.org/10.1128/mBio.02186-14
23. Baseman J B, Reddy S P, Dallo S F. Interplay between mycoplasma surface proteins, airway cells, and the protean manifestations of mycoplasma-mediated human infections. Am J Respir Crit Care Med. 1996;154:S137–S143. https://dx.doi.org/10.1164/ajrccm/154.4_Pt_2.S137
24. Talkington D F, Waites K B, Schwartz S B, et al. Emerging from Obscurity: Understanding Pulmonary and Extrapulmonary Syndromes, Pathogenesis, and Epidemiology of Human Mycoplasma pneumoniae Infections. In Emerging Infections. 2014. https://doi.org/10.1128/9781555816988.ch4
25. Hu P C, Collier A M, Baseman JB. Interaction of virulent Mycoplasma pneumoniae with hamster tracheal organ cultures. Infect Immun. 1976;14:217–224. https://doi.org/10.1128/iai.14.1.217-224.1976
26. Berg C P, Kannan T R, Klein R, et al. Mycoplasma antigens as a possible trigger for the induction of antimitochondrial antibodies in primary biliary cirrhosis. Liver Int. 2009;29(6):797-809. https://doi.org/10.1111/j.1478-3231.2008.01942.x.
27. Park H, Li Z, Yang X O, et al. A distinct lineage of CD4 T cells regulates tissue inflammation by producing interleukin 17. Nat Immunol. 2005;6:1133–1141. https://doi.org/10.1038/ni1261
28. Macfarlane J. Mycoplasma pneumoniae infection, antibiotics and exanthema. Infection. 1980;8:119–120. https://doi.org/10.1007/BF01641475.
29. Leen C, Ling S. Mycoplasma infection and Kawasaki disease. Arch Dis Child. 1996; 75:266–267. https://doi.org/10.1136/adc.75.3.266-c.
30. Greco F, Sorge A, Salvo V, et al. Cutaneous vasculitis associated with Mycoplasma pneumoniae infection: case report and literature review. Clin Pediatr (Phila). 2007;46:451–453.
https://doi.org/10.1177/0009922806298638.
31. Bar Meir E, Amital H, Levy Y, et al. Mycoplasma pneumoniae-induced thrombotic thrombocytopenic purpura. Acta Haematol. 2000;103:112–115. https://doi.org/10.1159/000041030
32. Sneddon I B. Subcorneal pustules in erythema multiforme. Br J Dermatol. 1973;88: 605–607. https://doi.org/10.1111/j.1365-2133.1973.tb08026.x
33. Furioli J, Bourdon C, Le Loc’h H. Mycoplasma pneumoniae infection. Manifestation in a 3-year-old child by Raynaud’s phenomenon. Arch Fr Pediatr. 1985;42:313–314.
34. Latsch K, Girschick H J, Abele-Horn M. Stevens–Johnson syndrome without skin lesions. J Med Microbiol. 2007;56:1696–1699. https://doi.org/10.1099/jmm.0.47318-0
35. Meyer Sauteur P M, Goetschel P, Lautenschlager S. Mycoplasma pneumoniae and mucositis – part of the Stevens-Johnson syndrome spectrum. J Dtsch Dermatol Ges. 2012;10:740–746. https://doi.org/10.1111/j.1610-0387.2012.07951.x
36. Canavan T N, Mathes E F, Frieden I, et al. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2007;72:239–245. https://doi.org/10.1016/j.jaad.2014.06.026
37. Frantz G F, McAninch S A. Mycoplasma mucositis. In: StatPearls Publishing, Treasure Island, FL.
38. Meyer Sauteur P M, Theiler M, Buettcher M, et al. Frequency and clinical presentation of mucocutaneous disease due to Mycoplasma pneumoniae infection in children with community-acquired pneumonia. JAMA Dermatol. 2020;156:144–150. https://doi.org/10.1001/jamadermatol.2019.3602
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Mongolian National University of Medical Sciences
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
