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Erythema Multiforme

Clinical Cases

Case 1

  • 24-year-old woman with history of recurrent orolabial herpes infection
  • Presents with asymptomatic lesions on the palms (approximately 8 on each hand) and soles (approximately 4-5 on each foot) that developed one day after new vesicles developed on her lips
  • This is the first time she has developed skin lesions in association with her orolabial herpes
  • She reports no fever, respiratory or gastrointestinal symptoms

Initial evaluation

  • Exam reveals target lesions, approximately 1 cm in size on the palms and soles
  • Four small erosions on the lower left lip with hemorrhagic crusting
  • A diagnosis of HSV-associated EM minor is rendered
  • Since it has been several days since her orolabial herpetic flare, no antiviral therapy is given; the patient is counseled that if she develops frequent HSV recurrences with EM minor, she should return to the clinic for consideration of viral suppressive therapy
  • She is also counseled to use photoprotection, especially over the lips, to avoid triggering recurrent herpetic flares

Case 2

  • 17-year-old teenage boy presents with scattered skin lesions, oral erosions, eye pain, and 4 days’ history of cough
  • He has had subjective fevers and malaise over the past week
  • He denies taking any regular or occasional medications

Initial evaluation

  • The patient has fever, mild tachycardia, slight hypotension, with increased breathing rate and a slightly reduced oxygen saturation
  • Exam reveals scattered target lesions (approximately 5% body surface area) on the trunk, arms, legs; there are extensive superficial erosions on the lips and buccal mucosa with hemorrhagic crusting; he has marked conjunctival erythema and chemosis
  • Respiratory exam reveals reduced breath sounds throughout; a chest X-ray reveals diffuse pulmonary infiltrates and cold agglutinins done at the clinic bedside are positive
  • A diagnosis of mycoplasma-associated SJS is rendered
  • The patient is admitted to the hospital and there he is evaluated by infectious disease and ophthalmology, who confirm that he has mycoplasma pneumonia with mild ocular complications; later serologic testing confirms that he has active infection with Mycoplasma pneumoniae
  • The patient is hospitalized with supportive care and is given a course of antibiotics for mycoplasma pneumonia; skin and eye care are implemented; he is discharged two days later to home