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References

Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol. 2012; 51:889-902 https://doi.org/10.1111/j.1365-4632.2011.05348.x
Wolff K, Goldsmith L, Katz S Fitzpatrick's Dermatology in General Medicine.New York: McGraw Hill; 2008
Hammers CM, Stanley JR. Mechanisms of disease: pemphigus and bullous pemphigoid. Annu Rev Pathol. 2016; 11:175-197 https://doi.org/10.1146/annurev-pathol-012615-044313
Zaouak A, Daldoul M, Chamli A Cefixime-induced bullous erythema multiforme major. Int J Dermatol. 2022; https://doi.org/10.1111/ijd.16119

Letters to the editor

From Volume 49, Issue 7, July 2022 | Pages 602-603

Authors

Samah Khan

Department of Oral and Maxillofacial Surgery, Basildon University Hospital, Essex

Articles by Samah Khan

Shadaab Mumtaz

BDS, MFDS, RCPS (Glasg), ORE

Department of Oral and Maxillofacial Surgery, Royal Free London, NHS Foundation Trust, London, UK

Articles by Shadaab Mumtaz

Jamal Siddiqi

Department of Oral and Maxillofacial Surgery, Basildon University Hospital, Essex

Articles by Jamal Siddiqi

Article

A severe case of erythema multiforme in a 10-year-old boy

We wish to bring to your attention a case of a 10-year-old male who was admitted with a 5-day history of pyrexia, cough/cold symptoms and severe oropharyngeal blistering causing trismus and odynophagia (Figures 1 and 2). Additionally, this young boy also presented with bilateral conjunctivitis as well as ‘target’ skin lesions on the nose, chest, back and anogenital region. A working diagnosis of erythema multiforme major was formulated.

Figure 1.
Figure 2.

A multidisciplinary team including paediatrics, maxillofacial surgery, dermatology, ophthalmology and dietetics managed this young patient. Administration of intravenous fluids, antimicrobials, systemic as well as topical steroids and eventual nasogastric feeding due to reduced oral intake was necessary due to the severity of his symptoms. He stayed in hospital for 17 days and was discharged after improvement in symptoms and oral intake.

Erythema multiforme (EM) manifests as a rapid onset maculo-papular rash or ‘target lesions’ of the skin.1 Distinction is made between the cutaneous EM minor and the more severe EM major due to blistering/ulceration of two or more mucous membranes in the latter.2 Distinction from the severe and life-threatening Steven–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is necessary at an early stage to tailor the management. Similarly, pemphigus and pemphigoid, which are both autoimmune blistering diseases, present with oro-cutaneous manifestations.3 These conditions have similar features, often causing a diagnostic conundrum.

On the other hand, EM is identified as a hypersensitivity reaction like SJS/TEN.2 In most cases, either a viral/bacterial infection or medication is the causative factor.4 SJS/TEN is most likely a drug reaction compared to EM, which is mostly related to herpes simplex virus or Mycoplasma pneumoniae infection. It is often self-limiting, although severe forms can lead to hospitalization due to reduced oral intake and/or pain, such as that highlighted in this report. EM major will usually take 4–6 weeks to improve compared to 2–3 weeks in the case of EM minor.

Blistering diseases of the oral cavity remain poorly understood, compounded by the vast and varied manifestations. Multidisciplinary management is often necessary, especially in patients who experience morbid symptoms.