Clinical Characteristics of an outbreak of Mycoplasma pneumoniae -Associated Stevens - Johnson syndrome (SJS) in Children, Colorado, 2013

Background: Stevens Johnson Syndrom (SJS) is a rare, sporadic disease in children commonly associated with medications and infrequently associated with Mycoplasma pneumoniae (Mp). Outbreaks of SJS are rarely reported. From August through November 2013, an outbreak of SJS was identified at a pediatric hospital in Colorado.

Methods: SJS was defined as an acute illness characterized by inflammation of 2 or more mucous membranes and consistent skin lesions in a Colorado resident seeking care in Hospital A. In addition to performing a detailed chart review on all SJS cases, the departments of pediatric infectious disease and ophthalmology prospectively followed all cases. Respiratory specimens were tested for the presence of viral pathogens and Mp. At the CDC, confirmatory qPCR was performed, as well as culture and macrolide susceptibility profiling (using nested PCR with high-resolution melt (HRM) assay).

Results: From August 1 to November 30, 2013, nine children met criteria for SJS. Affected children had a median age of 14 years (range 8-16 years) and all were hospitalized. Six (66%) children were male, 3 (33%) presented with recurrent disease, and 8 (89%) had qPCR testing for Mp, of which 5 (63%) were positive. Of the 5 Mp-positive children, none had drug exposure prior to symptom onset; 1 was co-infected with a rhinovirus; all had preceding fever, cough, and radiographic pneumonia, with a mean of 3 days (range 0-5 days) between onset of respiratory symptoms and SJS lesions. All 5 Mp-positive children had severe ocular and mucus membrane involvement with minimal skin involvement, 2 (40%) required ICU admission, and 4 (80%) received amniotic membrane ocular grafts; 2 (40%) received IVIG; and all recovered fully. All Mp isolates were macrolide-susceptible. Of the 4 children who were not Mp-positive, 3 had a Mp-like respiratory illness and 2 were taking medications (Bactrim, amoxicillin) prior to lesion onset.

Conclusion: We report the largest outbreak of SJS in children, which was predominately associated with M. pneumoniae. The presentation of Mp-associated SJS was clinically distinct from other SJS, and clinicians should have a high suspicion for Mp-associated SJS when disease is characterized by severe ocular and mucous membrane involvement with minimal skin involvement and when lesions are preceded by respiratory symptoms.