Fever, Severe Mucositis, and Conjunctivitis in a 15-Year-Old Male

A 15-year-old previously healthy male began to have an isolated dry hacky cough without any respiratory distress. In the ensuing week, he developed a severe sore throat and a small oral ulcer. He was then seen by his pediatrician and received oral cefdinir for presumed pharyngitis; his symptoms did not improve. Two days later, he had a fever to 103.9°F (39.9°C), malaise, worsening mouth sores, bilateral conjunctivitis, and productive cough. He then presented to our emergency department for further evaluation, 10 days after his initial cough. On arrival to our emergency department, he was ill appearing with a temperature of 103.4°F (39.6°C), heart rate of 104 beats/min, respirations of 18 breaths/min, blood pressure of 151/71 mm Hg, and an oxygen saturation of 92% on room air. He had severe bilateral subconjunctival hemorrhages (Figure 1). Examination of the mouth was remarkable for markedly swollen, erythematous, crusted lips with yellow exudates and a swollen tongue. In addition, there was sloughing of the oral mucosa, which was erythematous and partially covered with serofibrinous exudates (Figure 2). No tonsillar exudates were noted. Respiratory examination was notable for discrete bilateral wheezes and rhonchi with slightly decreased breath sounds across the left lateral lobe. No skin or genital lesions were appreciated. The rest of the physical examination was unremarkable. Laboratory evaluation included a normal complete blood count, complete metabolic panel, and urinalysis. The C-reactive protein (CRP) was markedly elevated at 169.5 mg/L. A rapid streptococcal antigen detection test, a respiratory virus panel for community respiratory viruses, a herpes simplex virus (HSV) 1/2 polymerase chain reaction (PCR) from an oral swab, and a human immunodeficiency virus (HIV)–antibody test were negative. Blood and urine cultures were negative. An initial chest X-ray was normal. However, given the patient’s clinical presentation concerning for pneumonia, intravenous ceftriaxone was started and the patient was admitted for further evaluation and supportive care. At this point, several infectious etiologies were considered as a potential cause of his severe mucositis, including HSV and Mycoplasma pneumoniae. Twelve hours after admission, the patient became hypoxic, requiring oxygen via blow-by facemask. Discrete dry crackles across the left lower lobe were appreciated. A repeat chest radiograph was obtained, which demonstrated increasing basilar opacities consistent with pneumonia and a small left pleural effusion. Given his clinical deterioration with development of pneumonia along with severe oral mucositis and conjunctivitis, M pneumoniae–associated mucositis was suspected. Empiric intravenous azithromycin (500 mg daily) was started and ceftriaxone was discontinued. Dermatology and ophthalmology were consulted given the concern for atypical Stevens–Johnson syndrome (SJS) without skin involvement. Corneal abrasions were excluded, but the patient was advised to use erythromycin and white petrolatum ointment for lubrication as well as artificial tears for a small conjunctival abrasion. Additional supportive care included oral hygiene, parenteral hydration, and pain management with opioids.