Background:Mycoplasma pneumoniae atypical pneumonia is frequently associated with erythema multiforme. Occasionally, a mycoplasma infection does not trigger any cutaneous but exclusively mucosal lesions. The term mucosal respiratory syndrome is employed to denote the latter condition. Available reviews do not address the possible association of mucosal respiratory syndrome with further atypical bacterial pathogens such as Chlamydophila pneumoniae, Chlamydophila psittaci, Coxiella burnetii, Francisella tularensis, or Legionella species. We therefore performed a systematic review of the literature addressing this issue in the National Library of Medicine, Excerpta Medica, and Web of Science databases. Summary: We found 63 patients (≤18 years, n = 36; >18 years, n = 27; 54 males and 9 females) affected by a mucosal respiratory syndrome. Fifty-three cases were temporally associated with a M. pneumoniae and 5 with a C. pneumoniae infection. No cases temporally associated with C. psittaci, C. burnetii, F. tularensis, or Legionella species infection were found. Two cases were temporally associated with Epstein-Barr virus or influenzavirus B, respectively.

1.
Huff
JC
.
Erythema multiforme
.
Dermatol Clin
.
1985
Jan
;
3
(
1
):
141
52
.
[PubMed]
0733-8635
2.
Sokumbi
O
,
Wetter
DA
.
Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist
.
Int J Dermatol
.
2012
Aug
;
51
(
8
):
889
902
.
[PubMed]
0011-9059
3.
Lerch
M
,
Mainetti
C
,
Terziroli Beretta-Piccoli
B
,
Harr
T
.
Current perspectives on Stevens-Johnson syndrome and toxic epidermal necrolysis
.
Clin Rev Allergy Immunol
.
2018
Feb
;
54
(
1
):
147
76
.
[PubMed]
1080-0549
4.
Ludlam
GB
,
Bridges
JB
,
Benn
EC
.
Association of Stevens-Johnson syndrome with antibody for Mycoplasma pneumoniae
.
Lancet
.
1964
May
;
1
(
7340
):
958
9
.
[PubMed]
0140-6736
5.
Stanyon
JH
,
Warner
WP
.
Mucosal respiratory syndrome
.
Can Med Assoc J
.
1945
Nov
;
53
(
5
):
427
34
.
[PubMed]
0008-4409
6.
De Luigi
G
,
Kottanattu
L
,
Simonetti
GD
.
Perla pediatrica: polmonite associata a lesioni delle mucose
.
Trib Med Tic.
2020
;
85
(
1
):
22
3
.
7.
Jackson
JL
,
Kuriyama
A
,
Anton
A
,
Choi
A
,
Fournier
JP
,
Geier
AK
, et al.
The accuracy of Google translate for abstracting data from non-english-language trials for systematic reviews
.
Ann Intern Med
.
2019
Nov
;
171
(
9
):
677
9
.
[PubMed]
0003-4819
8.
Moher
D
,
Liberati
A
,
Tetzlaff
J
,
Altman
DG
;
PRISMA Group.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med.
2009
;151(4):264-269, W64.
9.
Bragg
F
;
Commission on Acute Respiratory Diseases
.
ASSOCIATION of pneumonia with erythema multiforme exudativum
.
Arch Intern Med (Chic)
.
1946
Dec
;
78
(
6
):
687
710
.
[PubMed]
0730-188X
10.
Sugarman
H
,
Baltzan
DM
.
Mucosal respiratory syndrome
.
Can Med Assoc J
.
1952
Jan
;
66
(
1
):
68
9
.
[PubMed]
0008-4409
11.
Sieber
OF
 Jr
,
John
TJ
,
Fulginiti
VA
,
Overholt
EC
.
Stevens-Johnson syndrome associated with Mycoplasma pneumoniae infection
.
JAMA
.
1967
Apr
;
200
(
1
):
79
81
.
[PubMed]
0098-7484
12.
Cannell
H
,
Churcher
GM
,
Milton-Thompson
GJ
.
Stevens-Johnson syndrome associated with Mycoplasma pneumoniae infection
.
Br J Dermatol
.
1969
Mar
;
81
(
3
):
196
9
.
[PubMed]
0007-0963
13.
Lods
F
,
Gramet
C
,
Ghenassia
C
.
Mycoplasma pneumoniae et syndrome bulleux des muqueuses
.
Bull Soc Ophtalmol Fr
.
1983
Feb
;
83
(
2
):
323
4
.
[PubMed]
0081-1270
14.
Welch
KJ
,
Burke
WA
,
Irons
TG
.
Recurrent erythema multiforme due to Mycoplasma pneumoniae
.
J Am Acad Dermatol
.
1987
Nov
;
17
(
5 Pt 1
):
839
40
.
[PubMed]
0190-9622
15.
Alter
SJ
,
Stringer
B
.
Mycoplasma pneumoniae infections associated with severe mucositis
.
Clin Pediatr (Phila)
.
1990
Oct
;
29
(
10
):
602
4
.
[PubMed]
0009-9228
16.
Salmon
P
,
Rademaker
M
.
Erythema multiforme associated with an outbreak of Mycoplasma pneumoniae function
.
N Z Med J
.
1993
Oct
;
106
(
966
):
449
50
.
[PubMed]
0028-8446
17.
Barfod
TS
,
Pedersen
C
.
Svaer stomatit udløst af infektion med mycoplasma pneumoniae
.
Ugeskr Laeger
.
1999
Nov
;
161
(
46
):
6363
4
.
[PubMed]
0041-5782
18.
Kirke
S
,
Powell
FC
.
Mucosal erosions and a cough
.
Ir Med J
.
2003
Sep
;
96
(
8
):
245
.
[PubMed]
0332-3102
19.
Vanfleteren
I
,
Van Gysel
D
,
De Brandt
C
.
Stevens-Johnson syndrome: a diagnostic challenge in the absence of skin lesions
.
Pediatr Dermatol
.
2003
Jan-Feb
;
20
(
1
):
52
6
.
[PubMed]
0736-8046
20.
Schalock
PC
,
Dinulos
JG
.
Mycoplasma pneumoniae-induced Stevens-Johnson syndrome without skin lesions: fact or fiction?
J Am Acad Dermatol
.
2005
Feb
;
52
(
2
):
312
5
.
[PubMed]
0190-9622
21.
de Ru
MH
,
Sukhai
RN
.
Stevens-Johnson syndrome
.
Eur J Pediatr
.
2007
Dec
;
166
(
12
):
1303
4
.
[PubMed]
0340-6199
22.
Fearon
D
,
Hesketh
EL
,
Mitchell
AE
,
Grimwood
K
.
Mycoplasma pneumoniae infection complicated by pneumomediastinum and severe mucositis
.
J Paediatr Child Health
.
2007
May
;
43
(
5
):
403
5
.
[PubMed]
1034-4810
23.
Latsch
K
,
Girschick
HJ
,
Abele-Horn
M
.
Stevens-Johnson syndrome without skin lesions
.
J Med Microbiol
.
2007
Dec
;
56
(
Pt 12
):
1696
9
.
[PubMed]
0022-2615
24.
Ravin
KA
,
Rappaport
LD
,
Zuckerbraun
NS
,
Wadowsky
RM
,
Wald
ER
,
Michaels
MM
.
Mycoplasma pneumoniae and atypical Stevens-Johnson syndrome: a case series
.
Pediatrics
.
2007
Apr
;
119
(
4
):
e1002
5
.
[PubMed]
0031-4005
25.
Hillebrand-Haverkort
ME
,
Budding
AE
,
bij de Vaate
LA
,
van Agtmael
MA
.
Mycoplasma pneumoniae infection with incomplete Stevens-Johnson syndrome
.
Lancet Infect Dis
.
2008
Oct
;
8
(
10
):
586
7
.
[PubMed]
1473-3099
26.
Sendi
P
,
Graber
P
,
Lepère
F
,
Schiller
P
,
Zimmerli
W
.
Mycoplasma pneumoniae infection complicated by severe mucocutaneous lesions
.
Lancet Infect Dis
.
2008
Apr
;
8
(
4
):
268
.
[PubMed]
1473-3099
27.
Walicka
M
,
Majsterek
M
,
Rakowska
A
,
Słowińska
M
,
Sicińska
J
,
Góralska
B
, et al.
Mycoplasma pneumoniae-induced pneumonia with Stevens-Johnson syndrome of acute atypical course
.
Pol Arch Med Wewn
.
2008
Jul-Aug
;
118
(
7-8
):
449
53
.
[PubMed]
0032-3772
28.
Artés Figueres
M
,
Oltra Benavent
M
,
Fernández Calatayud
A
,
Revert Gomar
M
.
Mucositis grave inducida por Mycoplasma pneumoniae
.
An Pediatr (Barc)
.
2009
Dec
;
71
(
6
):
573
4
.
[PubMed]
1695-4033
29.
Choi
SH
,
Lee
YM
,
Rha
YH
.
Mycoplasma pneumoniae-induced Stevens-Johnson syndrome without skin manifestations
.
Korean J Pediatr
.
2009
;
52
(
2
):
247
50
. 1738-1061
30.
Havliza
K
,
Jakob
A
,
Rompel
R
.
Erythema multiforme majus (Fuchs syndrome) associated with Mycoplasma pneumoniae infection in two patients
.
J Dtsch Dermatol Ges
.
2009
May
;
7
(
5
):
445
8
.
[PubMed]
1610-0387
31.
Villarroel
J
,
Bustamante
MC
,
Denegri
M
,
Pérez
L
.
Manifestaciones muco-cutáneas de la infección por Mycoplasma pneumoniae: presentación de cuatro casos
.
Rev Chilena Infectol
.
2009
Oct
;
26
(
5
):
457
63
.
[PubMed]
0716-1018
32.
Bressan
S
,
Mion
T
,
Andreola
B
,
Bisogno
G
,
Da Dalt
L
.
Severe Mycoplasma pneumoniae-associated mucositis treated with immunoglobulins
.
Acta Paediatr
.
2011
Nov
;
100
(
11
):
e238
40
.
[PubMed]
0803-5253
33.
McGouran
DC
,
Petterson
T
,
McLaren
JM
,
Wolbinski
MP
.
Mucositis, conjunctivitis but no rash - the “Atypical Stevens - Johnson syndrome”
.
Acute Med
.
2011
;
10
(
2
):
81
2
.
[PubMed]
1747-4892
34.
Meyer Sauteur
PM
,
Gansser-Kälin
U
,
Lautenschlager
S
,
Goetschel
P
.
Fuchs syndrome associated with Mycoplasma pneumoniae (Stevens-Johnson syndrome without skin lesions)
.
Pediatr Dermatol
.
2011
Jul-Aug
;
28
(
4
):
474
6
.
[PubMed]
0736-8046
35.
Ramasamy
A
,
Patel
C
,
Conlon
C
.
Incomplete Stevens-Johnson syndrome secondary to atypical pneumonia
.
BMJ Case Rep
.
2011
Oct
;
2011
oct03 1
:
0820114568
.
[PubMed]
1757-790X
36.
Strawn
JR
,
Whitsel
R
,
Nandagopal
JJ
,
Delbello
MP
.
Atypical Stevens-Johnson syndrome in an adolescent treated with duloxetine
.
J Child Adolesc Psychopharmacol
.
2011
Feb
;
21
(
1
):
91
2
.
[PubMed]
1044-5463
37.
Hochreiter
D
,
Jackson
JM
,
Shetty
AK
.
Fever, severe mucositis, and conjunctivitis in a 15-year-old male
.
Clin Pediatr (Phila)
.
2012
Nov
;
51
(
11
):
1103
5
.
[PubMed]
0009-9228
38.
Li
K
,
Haber
RM
.
Stevens-Johnson syndrome without skin lesions (Fuchs syndrome): a literature review of adult cases with Mycoplasma cause
.
Arch Dermatol
.
2012
Aug
;
148
(
8
):
963
4
.
[PubMed]
0003-987X
39.
Schomburg
J
,
Vogel
M
.
A 12-year-old boy with severe mucositis: extrapulmonary manifestation of Mycoplasma pneumoniae infection
.
Klin Padiatr
.
2012
Mar
;
224
(
2
):
94
5
.
[PubMed]
0300-8630
40.
Trapp
LW
,
Schrantz
SJ
,
Joseph-Griffin
MA
,
Hageman
JR
,
Waskow
SE
.
A 13-year-old boy with pharyngitis, oral ulcers, and dehydration. Mycoplasma pneumoniae-associated mucositis
.
Pediatr Ann
.
2013
Apr
;
42
(
4
):
148
50
.
[PubMed]
0090-4481
41.
Milner
TL
,
Gomez Mendez
LM
.
Stevens-Johnson syndrome, mucositis, or something else?
Hosp Pediatr
.
2014
Jan
;
4
(
1
):
54
7
.
[PubMed]
2154-1663
42.
Yachoui
R
,
Kolasinski
SL
,
Feinstein
DE
.
Mycoplasma pneumoniae with atypical stevens-johnson syndrome: a diagnostic challenge
.
Case Rep Infect Dis
.
2013
;
2013
:
457161
.
[PubMed]
2090-6625
43.
Šternberský
J
,
Tichý
M
.
Fuchs’ syndrome (Stevens-Johnson syndrome without skin involvement) in an adult male—a case report and general characteristics of the sporadically diagnosed disease
.
Acta Dermatovenerol Croat
.
2014
;
22
(
4
):
284
7
.
[PubMed]
1847-6538
44.
Varghese
C
,
Sharain
K
,
Skalski
J
,
Ramar
K
.
Mycoplasma pneumonia-associated mucositis
.
BMJ Case Rep
.
2014
Mar
;
2014
mar13 1
:
2014203795
.
[PubMed]
1757-790X
45.
Anders
UM
,
Taylor
EJ
,
Kravchuk
V
,
Martel
JR
,
Martel
JB
.
Stevens-Johnson syndrome without skin lesions: a rare and clinically challenging disease in the urgent setting
.
Emerg Med Open J.
2015
;
1
(
2
):
22
30
.
46.
Majima
Y
,
Ikeda
Y
,
Yagi
H
,
Enokida
K
,
Miura
T
,
Tokura
Y
.
Colonic involvement in Stevens-Johnson syndrome-like mucositis without skin lesions
.
Allergol Int
.
2015
Jan
;
64
(
1
):
106
8
.
[PubMed]
1323-8930
47.
Mangal
S
,
Narang
T
,
Saikia
UN
,
Kumaran
MS
.
Fuchs syndrome or erythema multiforme major, uncommon or underdiagnosed?
Indian J Dermatol Venereol Leprol
.
2015
Jul-Aug
;
81
(
4
):
403
5
.
[PubMed]
0378-6323
48.
Vujic
I
,
Shroff
A
,
Grzelka
M
,
Posch
C
,
Monshi
B
,
Sanlorenzo
M
, et al.
Mycoplasma pneumoniae-associated mucositis—case report and systematic review of literature
.
J Eur Acad Dermatol Venereol
.
2015
Mar
;
29
(
3
):
595
8
.
[PubMed]
0926-9959
49.
Alcántara-Reifs
CM
,
García-Nieto
AV
.
Mycoplasma pneumoniae-associated mucositis
.
CMAJ
.
2016
Jul
;
188
(
10
):
753
.
[PubMed]
0820-3946
50.
Kurata
M
,
Kano
Y
,
Sato
Y
,
Hirahara
K
,
Shiohara
T
.
Synergistic Effects of Mycoplasma pneumoniae infection and drug reaction on the development of atypical Stevens-Johnson syndrome in adults
.
Acta Derm Venereol
.
2016
Jan
;
96
(
1
):
111
3
.
[PubMed]
0001-5555
51.
Contestable
JJ
,
Ward
ML
.
A case of Mycoplasma pneumoniae-associated mucositis
.
Consultant
.
2017
;
57
(
12
):
698
9
.0010-7069
52.
De Andrés
B
,
Tejeda
V
,
Arrozpide
L
.
Mucositis por Mycoplasma: un caso clínico que apoya su diferenciación del síndrome de Stevens Johnson
.
Med Cutan Ibero Lat Am
.
2017
;
45
(
3
):
224
7
.0210-5187
53.
Gossart
R
,
Malthiery
E
,
Aguilar
F
,
Torres
JH
,
Fauroux
MA
.
Fuchs syndrome: medical treatment of 1 case and literature review
.
Case Rep Dermatol
.
2017
Apr
;
9
(
1
):
114
20
.
[PubMed]
1662-6567
54.
Kheiri
B
,
Alhesan
NA
,
Madala
S
,
Assasa
O
,
Shen
M
,
Dawood
T
.
Mycoplasma pneumoniae-associated Fuchs syndrome
.
Clin Case Rep
.
2017
Dec
;
6
(
2
):
434
5
.
[PubMed]
2050-0904
55.
Mayor-Ibarguren
A
,
Feito-Rodriguez
M
,
González-Ramos
J
,
Del Rosal-Rabes
T
,
González-Sainz
FJ
,
Sánchez-Orta
A
, et al.
Mucositis secondary to Chlamydia pneumoniae infection: expanding the Mycoplasma pneumoniae-induced rash and mucositis concept
.
Pediatr Dermatol
.
2017
Jul
;
34
(
4
):
465
72
.
[PubMed]
0736-8046
56.
Shihadeh
MD
.
Mycoplasma pneumonia-induced rash and mucositis
.
Bahrain Med Bull
.
2017
;
39
(
2
):
126
7
. 1012-8298
57.
Bowling
M
,
Schmutzler
T
,
Glick
S
.
Mycoplasma pneumoniae-induced mucositis without rash in an 11-year-old boy
.
Clin Case Rep
.
2018
Feb
;
6
(
3
):
551
2
.
[PubMed]
2050-0904
58.
Espinoza-Camacho
D
,
Monge-Ortega
OP
,
Sedó-Mejía
G
.
Síndrome de Steven-Johnson atípico inducido por Mycoplasma pneumoniae: un reto diagnóstico
.
Rev Alerg Mex
.
2018
Oct-Dec
;
65
(
4
):
437
41
.
[PubMed]
0002-5151
59.
Zão
I
,
Ribeiro
F
,
Rocha
V
,
Neto
P
,
Matias
C
,
Jesus
G
.
Mycoplasma pneumoniae-associated mucositis: a recently described entity
.
Eur J Case Rep Intern Med
.
2018
Nov
;
5
(
11
):
000977
.
[PubMed]
2284-2594
60.
Demitsu
T
,
Kawase
M
,
Nagashima
K
,
Takazawa
M
,
Yamada
T
,
Kakurai
M
, et al.
Mycoplasma pneumoniae-associated mucositis with severe blistering stomatitis and pneumonia successfully treated with azithromycin and infusion therapy
.
J Dermatol
.
2019
Jan
;
46
(
1
):
e38
9
.
[PubMed]
0385-2407
61.
Hildebrandt
ME
,
Agersted
AB
,
Sejersen
TS
,
Homøe
P
.
[Mycoplasma pneumoniae-associated mucositis in a 17-year-old girl]
.
Ugeskr Laeger
.
2019
Oct
;
181
(
43
):
V07190377
.
[PubMed]
1603-6824
62.
Umapathi
KK
,
Tuli
J
,
Menon
S
.
Chlamydia pneumonia - induced mucositis
.
Pediatr Neonatol
.
2019
Dec
;
60
(
6
):
697
8
.
[PubMed]
1875-9572
63.
Brazel
D
,
Kulp
B
,
Bautista
G
,
Bonwit
A
. Rash and mucositis associated with Mycoplasma pneumoniae and Chlamydophila pneumoniae: a recurrence of MIRM? J Pediatric Infect Dis Soc.
2020
Apr
10
:piaa028.
64.
Müller
A
,
McGhee
CN
.
Professor Ernst Fuchs (1851-1930): a defining career in ophthalmology
.
Arch Ophthalmol
.
2003
Jun
;
121
(
6
):
888
91
.
[PubMed]
0003-9950
65.
Canavan
TN
,
Mathes
EF
,
Frieden
I
,
Shinkai
K
.
Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review
.
J Am Acad Dermatol
.
2015
Feb
;
72
(
2
):
239
45
.
[PubMed]
0190-9622
66.
Amode
R
,
Ingen-Housz-Oro
S
,
Ortonne
N
,
Bounfour
T
,
Pereyre
S
,
Schlemmer
F
, et al.
Clinical and histologic features of Mycoplasma pneumoniae-related erythema multiforme: A single-center series of 33 cases compared with 100 cases induced by other causes
.
J Am Acad Dermatol
.
2018
Jul
;
79
(
1
):
110
7
.
[PubMed]
0190-9622
67.
Canter
NB
,
Smith
LM
.
Incomplete Stevens-Johnson Syndrome Caused by Sulfonamide Antimicrobial Exposure
.
Clin Pract Cases Emerg Med
.
2019
May
;
3
(
3
):
240
2
.
[PubMed]
2474-252X
68.
Vismara
SA
,
Lava
SA
,
Kottanattu
L
,
Simonetti
GD
,
Zgraggen
L
,
Clericetti
CM
, et al.
Lipschütz’s acute vulvar ulcer: a systematic review
.
Eur J Pediatr
.
2020
Oct
;
179
(
10
):
1559
67
.
[PubMed]
0340-6199
69.
De Luigi
G
,
Zgraggen
L
,
Kottanattu
L
,
Simonetti
GD
,
Terraneo
L
,
Vanoni
F
, et al.
Skin and Mucous Membrane Eruptions Associated with Chlamydophila Pneumoniae Respiratory Infections: literature Review
.
Dermatology
.
2020
Mar
;
•••
:
1
6
.
[PubMed]
1018-8665
70.
McPherson
T
,
Exton
LS
,
Biswas
S
,
Creamer
D
,
Dziewulski
P
,
Newell
L
, et al.
British Association of Dermatologists’ guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in children and young people, 2018
.
Br J Dermatol
.
2019
Jul
;
181
(
1
):
37
54
.
[PubMed]
0007-0963
71.
Recalcati
S
.
Cutaneous manifestations in COVID-19: a first perspective
.
J Eur Acad Dermatol Venereol
.
2020
May
;
34
(
5
):
e212
3
.
[PubMed]
0926-9959
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.