Reactive infectious mucocutaneous eruption - repeat etanercept after intravenous immunoglobulin: A case report

Abstract

Reactive infectious mucocutaneous eruption is a recently distinguished mucosal-predominant blistering eruption triggered by respiratory infections. We describe a previously healthy 11-year-old Black female with rapidly progressive mucocutaneous blistering after prodromal respiratory infection symptoms. Reactive infectious mucocutaneous eruption was suspected and treated with systemic corticosteroids followed by etanercept. Twenty-four hours after etanercept, the diagnosis of multisystem inflammatory syndrome in children was raised and intravenous immunoglobulin was given. Rapidly worsening mucocutaneous disease ensued but was controlled by a second dose of etanercept. Our case highlights the following: (1) the novel observation of possible interaction/neutralization of etanercept by intravenous immunoglobulin, (2) the challenging differential diagnosis of multisystem inflammatory syndrome in children for reactive infectious mucocutaneous eruption patients in the Coronavirus disease 2019 (COVID-19) pandemic, and (3) the role of early treatment to prevent dyspigmentation.

Keywords: Coronavirus disease 2019; Etanercept; intravenous immunoglobulin; mycoplasma-induced rash and mucositis; reactive infectious mucocutaneous eruption.

Figure 1.

(a and b) Facial and truncal blistering, and hemorrhagic oral mucositis at initial presentation (20% BSA involvement).

Figure 2.

(a–d) Progression of tense cutaneous blisters and hemorrhagic oral mucositis 24 h post-IVIG on day 4 (35% BSA involvement), prior to which she had received methylprednisolone and one dose of ETN.

Figure 3.

Resolution of tense blisters, drying of erosions, and halted progression after receiving the second dose of ETN subsequent to IVIG administration given 48 h prior. (a) Facial blistering with erosions and hemorrhagic oral mucositis 24 h after the second dose of ETN on day 6. (b–d) Hemorrhagic oral mucositis and diffuse vesicles and bullae on the trunk with skin sloughing 48 h after the second dose of ETN on day 7.

Figure 4.

Follow-up post-discharge 3 weeks after receiving second dose of ETN. (a and b) There is almost complete resolution of mucocutaneous lesions with only mild desquamation of vermillion lip remains. (c and d) Re-epithelialization has occurred in areas of previous blisters/erosions with minimal dyspigmentation.