Reactive Infectious Mucocutaneous Eruption

Aka: Reactive Infectious Mucocutaneous Eruption, RIME, Mycoplasma Pneumoniae Induced Rash And Mucositis, MIRM

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II. Definitions

  1. Reactive Infectious Mucocutaneous Eruption (RIME)
    1. Mucocutaneous eruption after a viral or Bacterial respiratory tract infection

III. Epidemiology

  1. Most common in children and teens following respiratory tract infection

IV. Causes

  1. Mycoplasma pneumoniae (original associated, preceding infection)
    1. Mycoplasma pneumoniae-induced rash and mucositis (MIRM)
  2. Adenovirus
  3. Chlamydia pneumoniae
  4. Human Metapneumovirus
  5. Influenza
  6. Parainfluenza
  7. Covid19

V. Signs

  1. Mucosal lesions (most common)
    1. Erosive mucositis of two or more mucous membranes
    2. Common regions
      1. Orolabial lesions (most common)
      2. Ocular (Conjunctivitis, Eyelid Edema)
      3. Urogenital lesions (Vesicles, erosions, ulcerations on penis, Scrotum, vulva, vagina, Urethral meatus)
    3. Other regions
      1. Anal mucositis
  2. Cutaneous lesions (less common)
    1. Macules and Papules
    2. Bullous lesions or target lesions suggest alternative diagnosis (e.g. Erythema Multiforme)

VI. Diagnosis

  1. Two or more mucosal sites demonstrating lesions AND
  2. Cutaneous sites (if present) affect <10% of skin surface area

VII. Labs

  1. Herpes Simplex Virus Testing (e.g. HSV PCR) of Vesiculobullous lesions
  2. Consider Respiratory Panel nasal swab
    1. Mycloplasma Pneumoniae
    2. Chlamydia pneumoniae
    3. Influenza
    4. Covid19

VIII. Imaging

  1. Chest XRay
    1. Consider for Bacterial Pneumonia evaluation (mycloplasma Pneumoniae, Chlamydia pneumoniae)

IX. Differential Diagnosis

  1. See Mucositis
  2. See Oral Ulcer
  3. Orolabial Herpes (Herpes Simplex Virus)
  4. Kawasaki Disease (Conjunctivitis, persistent fever)
  5. Drug Eruption (e.g. drug induced necrolysis)
    1. Stevens Johnson Syndrome
    2. Toxic Epidermal Necrolysis

X. Management

  1. Self-limited and mild manifestations
  2. Treat underlying specific causes (e.g. Mycoplasma pneumoniae with Macrolides)
  3. Hydration with frequent oral fluids
    1. Intravenous Fluids as needed
  4. Maintain nutrition
    1. Prolonged inability to take oral intake may require nasogastric enteral feedings
  5. Supportive care
    1. Analgesics (suspensions may be better tolerated)
    2. Topical Ointments (e.g. aquaphor)
    3. Eye ointment (e.g. lacrilube)
    4. Mucosal adhesions (e.g. labial border)
      1. Apply frequent lubricants (e.g. eucerin, vaseline)
  6. Corticosteroids (consider)
    1. Dexamethasone 0.6 mg/kg up to 10 mg orally or IV once
  7. Severe cases (consult, weak evidence)
    1. Intravenous Immunoglobulin (IVIG)
      1. Ramien (2021) Clin Exp Dermatol 46(3): 420-9 [PubMed]
    2. Other immunomodulators
      1. Cyclosporine
      2. Anti-Tumor Necrosis Factor

XI. Prognosis

  1. Typically self limited and resolves with supportive care
  2. May be recurrent in 8% of patients (based on experience with Mycoplasma associated cases)

XII. Resources

  1. Understanding Reactive Infectious Mucocutaneous Eruption (Dr. Introcaso, Derm Digest)
    1. https://thedermdigest.com/understanding-reactive-infectious-mucocutaneous-eruption-rime/

XIII. References

  1. Smallwood and Crawford (2024) Crit Dec Emerg Med 38(9): 16-8
  2. Canavan (2015) J Am Acad Dermatol 72(2):239-45 +PMID: 25592340 [PubMed]
  3. Gámez-González (2021) Pediatr Dermatol 38(1):306-8 +PMID: 33063905 [PubMed]
  4. HIrai (2023) Am Fam Physician 108(5): 509-10 [PubMed]
  5. Ramien (2020) JAMA Dermatol 156(2):124-5 +PMID: 31851301 [PubMed]

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