A 64‐year‐old woman with a medical history of asthma, chronic obstructive pulmonary disease, and hypertension presented with painful swelling of the lips, tongue, and neck. She had been suffering from several weeks of cough and nasal congestion and was being treated with amoxicillin for a sinus infection. The swelling began acutely four nights prior to admission, and was accompanied by rhinorrhea, frequent throat clearing, odynophagia, and subjective fevers. At this time she discontinued her amoxicillin with concern for drug allergy. She was unable to close her mouth due to the swelling, and presented to the ED for worsening pain. Of note, she had one prior episode with less severe lip and mouth swelling eight weeks prior to admission, and was treated with antibiotics for a dental infection. Her initial physical exam was significant for painful edema of the lips, tongue, and soft tissue of the anterior neck with 2–3 palpable small lymph nodes. Her mucous membranes were dry and erythematous with superficial sloughing, and she had sailorrhea. Her gingiva were dusky and tender to palpation. A complete skin exam was negative for ulcerations and bullae. Laboratory studies were significant for elevated ESR and CRP. Blood and sputum cultures and serum HSV studies were negative. However serum mycoplasma IgM antibody was positive. ENT service performed laryngoscopy, which confirmed glossitis, mucositis, and angioedema with no obvious infection. Panorex and CT neck were both negative for abscess. An allergy consult was also obtained with concern for hereditary or drug‐related angioedema, but this was unlikely given time course. The patient was ultimately diagnosed with erythema multiforme (EM) due to mycoplasma pneumoniae. Patient received IV Decadron, dexamethasone mouthwash, and viscous lidocaine, and her symptoms improved. She was treated with a ten‐day course of azithromycin and was advised to avoid amoxicillin medications.
This case highlights an important subset of EM that is confined to the oral mucosa. EM is most often associated with infectious etiology, with HSV being the most common precipitant. Mycoplasma pneumoniae is another well‐defined cause of EM, but is more frequently seen in the pediatric population and is accompanied by respiratory symptoms. Differential diagnosis of glossitis and mucositis includes immunologic processes such as Stevens–Johnson syndrome, drug rash, pemphigoid, and urticaria as well as Bechet's and Crohn's diseases. Infection must also be ruled out. Although biopsy may be helpful, oral EM is ultimately a diagnosis of exclusion. As hospitalists are often the first to encounter patients with severe symptoms, early recognition of this rare clinical syndrome can hasten patient recovery.
The purpose of this case presentation is to highlight an underrecognized clinical syndrome as well as to provide hospitalists with insight into diagnosis of severe symptoms of mucositis and glossitis.
To cite this abstract:Desai N, Patel K. Erythema Multiforme “Walks” in. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 449. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/erythema-multiforme-walks-in/. Accessed April 2, 2020.