Reactive Infectious Mucocutaneous Eruption secondary to Chlamydia pneumoniae infection in a 19-year-old: a case report
This article has been Reviewed by the following groups
Discuss this preprint
Start a discussion What are Sciety discussions?Listed in
This article is not in any list yet, why not save it to one of your lists.Abstract
Introduction Reactive Infectious Mucocutaneous Eruption (RIME) is a phenomenon that occurs predominantly in children and young adults following a bacterial or viral respiratory infection. RIME is most associated with Mycoplasma pneumoniae and generally presents with extensive mucosal and limited cutaneous involvement. Less commonly, infection with Chlamydia pneumoniae can trigger cutaneous eruptions but seldom leads to isolated mucosal involvement. Here, we describe a rare case of RIME mucositis secondary to Chlamydia pneumoniae respiratory infection. Case Report An otherwise healthy 19-year-old male presented with fever, cough, conjunctivitis, dysuria, and oral mucositis with ulceration preventing food intake. Chlamydia pneumoniae was detected on nasopharyngeal swab by a commercial multiplex PCR (BioFire Respiratory 2.1 Panel) while broad workup of alternative infectious and autoimmune causes was unremarkable. Despite supportive care, antibiotics, and initial steroid treatment, his mucositis necessitated hospital admission and eventually steroid regimen intensification before fully resolving. Conclusion While rare, Chlamydia pneumoniae should be considered as a possible trigger of RIME in adolescents and young adults. Multiplex PCR assays capable of detecting atypical pneumonia pathogens such as C. pneumoniae and M. pneumoniae can assist in diagnosing patients presenting with RIME-compatible symptoms. Treatment involves supportive care, antibiotics and steroids if mucositis is severe. Steroid escalation may be beneficial in patients with slow-resolving mucositis.
Article activity feed
-
-
Overall, this is a strong case report that is likely suitable for publication following major revisions. The comments below are intended to improve clarity, emphasis, and editorial polish. Title: Consider refining the title to emphasize the case-report nature and the association with pneumonia (e.g., including “pneumonia” or “case report”) to improve clarity and discoverability. Abstract: Strengthen the abstract by more explicitly highlighting the rarity and novelty of C. pneumoniae–associated RIME, particularly mucosal-predominant disease. Also, consider briefly noting the diagnostic role of multiplex PCR and the need for steroid escalation. Introduction: The background is appropriate but could be slightly condensed to reduce repetition. Also, strengthen the final sentence to more clearly state the gap in existing literature and the …
Overall, this is a strong case report that is likely suitable for publication following major revisions. The comments below are intended to improve clarity, emphasis, and editorial polish. Title: Consider refining the title to emphasize the case-report nature and the association with pneumonia (e.g., including “pneumonia” or “case report”) to improve clarity and discoverability. Abstract: Strengthen the abstract by more explicitly highlighting the rarity and novelty of C. pneumoniae–associated RIME, particularly mucosal-predominant disease. Also, consider briefly noting the diagnostic role of multiplex PCR and the need for steroid escalation. Introduction: The background is appropriate but could be slightly condensed to reduce repetition. Also, strengthen the final sentence to more clearly state the gap in existing literature and the specific contribution of this case. Case Presentation: Clarify the clinical timeline, particularly the relationship between antibiotic exposure and onset of mucosal symptoms, to further support exclusion of SJS/TEN. Furthermore, minor stylistic edits (e.g., avoiding first-person phrasing such as “we felt”) would improve academic tone. Diagnostic Workup: Consider explicitly stating that Mycoplasma pneumoniae testing was negative (if applicable) and whether serologic testing was performed or deferred Discussion: The discussion is thorough and well referenced but could benefit from modest reorganization for flow. More explicitly state what makes this case unique (mucosal-only involvement, PCR-confirmed C. pneumoniae, need for steroid escalation). A brief concluding sentence reinforcing the clinical takeaway would strengthen the section. Table and Figures: Table 1 is useful; consider minor formatting and wording simplification for readability. Figure 1, ensure that patient consent explicitly covers publication of identifiable facial images. Language and Style: The manuscript is largely well written; only minor line edits are needed for sentence length, hyphenation consistency, and neutral academic phrasing.
-
Comments to Author
The description of the case is generally clear and concise, with the presentation and investigation described clearly. I thought the report was structured well and the timeline of the case was easy to follow. The literature review and discussion are relevant and informative. A record of the patients consent to publish has also been included. Given the relatively few reports of Chlamydia-associated RIME additional case reports will add to both clinical awareness and epidemiological data, however I wonder if the paper may be strengthened by comparing this presentation to others in the literature - is this a typical case or are there features that differ from those previously reported? His initial treatment from his family physician is recorded (lines 49-50) but without dosing information. (Again, no …
Comments to Author
The description of the case is generally clear and concise, with the presentation and investigation described clearly. I thought the report was structured well and the timeline of the case was easy to follow. The literature review and discussion are relevant and informative. A record of the patients consent to publish has also been included. Given the relatively few reports of Chlamydia-associated RIME additional case reports will add to both clinical awareness and epidemiological data, however I wonder if the paper may be strengthened by comparing this presentation to others in the literature - is this a typical case or are there features that differ from those previously reported? His initial treatment from his family physician is recorded (lines 49-50) but without dosing information. (Again, no dosing information is given for his in-patient antimicrobials on lines 68 and 87.) Is this empirical therapy for CAP in line with local guidelines (would commonly expect to see e.g. amoxicillin as empirical therapy for CAP in the absence of beta-lactam allergy (line 53)), and was there any severity scoring recorded? Were the described symptoms present at the time he was seen in the community (lines 48-49) stable, or was there evolution of these symptoms over time? When did the oral ulceration and dysuria appear? As the authors work in Canada I assume the patient was also from Canada, but was he born there or had he moved from elsewhere (i.e. was he fully vaccinated to Canadian guidelines or some other childhood vaccination schedule (line 53))? Some laboratory findings are reported (lines 64-65), however no reference ranges are included which may aid interpretation (for example, the leucocyte range reported by Mayor-Ibarguren et al. was 9-13, whereas Lau et al. used 3.5-8.8 - knowing what 'normal' is for the assay would help interpret the 'mild leukocytosis' in line 64). Lines 77 to 85 describe the panel of microbiological investigations that were performed for this case, however the only specific methodology described is the BioFire. How much of the testing was available in-house (and therefore had a quick turn-around time presumably), and what commercial assays were used, and which had to be sent away? On lines 68 to 70 the infection control precautions put in place for possible measles are described; were these discontinued before or after measles-specific results were available? His throat swab was positive for Chlamydia whereas the sputum was negative (lines 83-84); were these also tested by the BioFire as described for the nasopharyngeal swab? Were any other samples tested for Mycoplasma species (e.g. urinary M. genitalium or M. hominis); although not reported as causing RIME (as that appears to be associated specifically with respiratory infection whereas the Mycoplasma species are typically urogenital), pneumonia caused by M. hominis is described (e.g. Panchuka and Hankins, BMJ Case Reports CP 2023;16:e250107. https://doi.org/10.1136/bcr-2022-250107) and would be missed by the BioFire panel (a case report of RIME caused by a non-pneumoniae Mycoplasma species would be novel)? His steroid treatment is described on lines 90-91, however without knowing his weight we don't know how close to the 1 mg/kg/day mentioned in the discussion (line 125). His odynophagia and dysuria are described as resolving after 4 days of steroids (line 92) but how long did it take for his new genital ulcers to resolve (line 89)? How long was his tapering steroid course on discharge? Had all his lesions resolved successfully at his dermatology follow up (line 93)? Table 1 lists diagnostic and treatment criteria for RIME; for the diagnostic criteria Canavan et al. are referenced on line 95 (but not in the table itself), however no references are given for the treatment criteria either in the text (line 117 onwards) or the table, with the exception of Mayor-Ibarguren et al. steroid dosing recommendation on line 125.
Please confirm that no generative AI tools or large language models have been used to generate this peer review report or to assist with any part of the peer review process.
I confirm no generative AI tools were used in preparation of this review.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-
-
Comments to Author
Why are doxycycline and clarithromycin prescribed together for presumed community-acquired pneumonia (CAP)? Additionally, if the cause of the CAP is Chlamydia pneumoniae, why might respiratory symptoms fail to resolve after using clarithromycin? Please clarify.
Please confirm that no generative AI tools or large language models have been used to generate this peer review report or to assist with any part of the peer review process.
I confirm no generative AI tools were used in preparation of this review.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any …
Comments to Author
Why are doxycycline and clarithromycin prescribed together for presumed community-acquired pneumonia (CAP)? Additionally, if the cause of the CAP is Chlamydia pneumoniae, why might respiratory symptoms fail to resolve after using clarithromycin? Please clarify.
Please confirm that no generative AI tools or large language models have been used to generate this peer review report or to assist with any part of the peer review process.
I confirm no generative AI tools were used in preparation of this review.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-