26344 Recurrent reactive infectious mucocutaneous eruption (RIME) caused by human metapneumovirus

Abstract

Reactive infectious mucocutaneous eruption (RIME) was recently proposed by Ramien et al to encompass mucocutaneous eruptions previously diagnosed as Mycoplasma pneumoniae induced rash and mucositis (MIRM) that are caused by nonmycoplasma pathogens. The pathogenesis is thought to involve immune complex deposition, complement activation, and molecular mimicry that leads to mucositis with limited skin involvement. We describe a unique case of recurrent RIME in a teenage patient with two different triggering pathogens. A healthy 13-year-old male presented with cough and fever for two weeks and sores of the throat and lips for one day. Upon examination, there was extensive eschars and sloughing with bleeding of lips and diffuse sloughing of the oral mucosa and tongue. He also had noncoalescing, purple eschars on the scrotum, penile length, and meatus. Mycoplasma titers were positive, and the patient was diagnosed with MIRM without skin involvement—symptoms improved with supportive measures and azithromycin. Four years following the initial episode, the 17-year-old patient presented with throat and mouth pain for five days with fever. He endorsed flu-like symptoms a week prior to presentation. On examination, there were confluent erosions of the mucosal lips and numerous ill-defined erosions on the buccal cheek and palate. Ill-defined erosions were also present on the penile head. Azithromycin was initiated for presumed recurrent MIRM, but Mycoplasma titers returned negative. Further workup demonstrated human metapneumovirus (hMPV) infection and the patient was diagnosed with reactive mucositis secondary to hMPV. To our knowledge, this is the first case of recurrent RIME caused by hMPV.