Brian Harte, MD, FACP, FHM

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 50‐year‐old female patient with a past medical history of Sjogren's syndrome and polymyositis presented with fever, rash, swelling, and pain in her extremities. Skin biopsy confirmed vasculitis. She was treated with steroids and azathioprine. However, she developed sudden‐onset central visual blurring in her right eye on the fifth day of hospitalization. Fundoscopic exam showed multiple central white‐centered retinal hemorrhages (Roth spots, Figures 1, 2) and vascular sheathing, consistent with retinal vasculitis. Blood cultures were negative. Transthoracic and transesophageal echocardiograms were normal. She was treated with high‐dose intravenous steroids and cyclophosphamide, with visual improvement and a marked reduction in the number of Roth spots.

Figure 1

Figure 2

Roth spots 1 are nonspecific intraretinal hemorrhagic lesions with a white center due to fibrin deposition. Although historically associated with infective endocarditis, they can also occur in other systemic diseases such as connective tissue disorders, vasculitis, leukemia, diabetes, hypertension, anemia, trauma, as well as disseminated bacterial and fungal infections.

A 15‐year‐old male was hospitalized with painful blisters on the lips and ulcers in the oral mucosa that were preceded by upper respiratory infection symptoms for 1 week. He had not been treated with antimicrobials. He subsequently developed conjunctival injection and painful blisters at the urethral meatus and symmetric scattered target lesions in the extremities. Examination demonstrated low‐grade fever, mild conjunctival injection (Figure 2), and oral vesicular lesions affecting the lips (Figure 1) and both the hard and soft palate; he had vesicular lesions affecting the glans penis, a ruptured vesicle at the urethral meatus and target lesions in the arms (Figure 3) and legs (Figure 4). His cardiopulmonary exam was normal. He was started on acyclovir and azithromycin, and symptomatic treatment with oral lidocaine and morphine. Serologies for Epstein‐Barr virus (EBV), cytomegalovirus (CMV) and Coxsackievirus and cultures for herpes simplex virus (HSV) were negative. Mycoplasma pneumoniae immunoglobulin G (IgG) and IgM titers were significantly elevated (>4‐fold) and the diagnosis made of Stevens‐Johnson syndrome (SJS) secondary to Mycoplasma pneumoniae infection. He was able to tolerate oral intake after a 1‐week hospital course.

M. pneumoniae infection can cause mucocutaneous involvement varying from mild mucositis to SJS with significant morbidity and mortality, 1, 2 mostly in the pediatric population. The differential diagnosis includes HSV, Kawasaki, and Streptococcal toxic shock syndrome, as well as other viral infections (eg, Coxsackievirus).3 Pharmacologic causesespecially antibiotics, non steroidal anti‐inflammatory drug (NSAIDS) and anticonvulsantsshould also be considered in the etiology of SJS4 especially in the adult population.

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Figure 4

A 15‐year‐old male was hospitalized with painful blisters on the lips and ulcers in the oral mucosa that were preceded by upper respiratory infection symptoms for 1 week. He had not been treated with antimicrobials. He subsequently developed conjunctival injection and painful blisters at the urethral meatus and symmetric scattered target lesions in the extremities. Examination demonstrated low‐grade fever, mild conjunctival injection (Figure 2), and oral vesicular lesions affecting the lips (Figure 1) and both the hard and soft palate; he had vesicular lesions affecting the glans penis, a ruptured vesicle at the urethral meatus and target lesions in the arms (Figure 3) and legs (Figure 4). His cardiopulmonary exam was normal. He was started on acyclovir and azithromycin, and symptomatic treatment with oral lidocaine and morphine. Serologies for Epstein‐Barr virus (EBV), cytomegalovirus (CMV) and Coxsackievirus and cultures for herpes simplex virus (HSV) were negative. Mycoplasma pneumoniae immunoglobulin G (IgG) and IgM titers were significantly elevated (>4‐fold) and the diagnosis made of Stevens‐Johnson syndrome (SJS) secondary to Mycoplasma pneumoniae infection. He was able to tolerate oral intake after a 1‐week hospital course.

M. pneumoniae infection can cause mucocutaneous involvement varying from mild mucositis to SJS with significant morbidity and mortality, 1, 2 mostly in the pediatric population. The differential diagnosis includes HSV, Kawasaki, and Streptococcal toxic shock syndrome, as well as other viral infections (eg, Coxsackievirus).3 Pharmacologic causesespecially antibiotics, non steroidal anti‐inflammatory drug (NSAIDS) and anticonvulsantsshould also be considered in the etiology of SJS4 especially in the adult population.

Figure 1

Figure 2

Figure 3

Figure 4

A 15‐year‐old male was hospitalized with painful blisters on the lips and ulcers in the oral mucosa that were preceded by upper respiratory infection symptoms for 1 week. He had not been treated with antimicrobials. He subsequently developed conjunctival injection and painful blisters at the urethral meatus and symmetric scattered target lesions in the extremities. Examination demonstrated low‐grade fever, mild conjunctival injection (Figure 2), and oral vesicular lesions affecting the lips (Figure 1) and both the hard and soft palate; he had vesicular lesions affecting the glans penis, a ruptured vesicle at the urethral meatus and target lesions in the arms (Figure 3) and legs (Figure 4). His cardiopulmonary exam was normal. He was started on acyclovir and azithromycin, and symptomatic treatment with oral lidocaine and morphine. Serologies for Epstein‐Barr virus (EBV), cytomegalovirus (CMV) and Coxsackievirus and cultures for herpes simplex virus (HSV) were negative. Mycoplasma pneumoniae immunoglobulin G (IgG) and IgM titers were significantly elevated (>4‐fold) and the diagnosis made of Stevens‐Johnson syndrome (SJS) secondary to Mycoplasma pneumoniae infection. He was able to tolerate oral intake after a 1‐week hospital course.

M. pneumoniae infection can cause mucocutaneous involvement varying from mild mucositis to SJS with significant morbidity and mortality, 1, 2 mostly in the pediatric population. The differential diagnosis includes HSV, Kawasaki, and Streptococcal toxic shock syndrome, as well as other viral infections (eg, Coxsackievirus).3 Pharmacologic causesespecially antibiotics, non steroidal anti‐inflammatory drug (NSAIDS) and anticonvulsantsshould also be considered in the etiology of SJS4 especially in the adult population.

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