ALLERGOL. ET IMMUNOPATHOL., 1998;26(6):283-287
CLINICAL REVIEW
Erythema multiforme: a review of twenty cases
M. A. Martín Mateos*, A. Roldán Ros and F. Muñoz-López
*Sección de Inmunología y Alergia. Unidad Integrada de Pediatría. Hospital Clínico-Hospital de San Juan de Dios. Universidad de Barcelona.
SUMMARY
The clinical histories of twenty children hospitalized for erythema multiforme (EM) were reviewed. Three forms of the illness were defined according to clinical criteria: minor (EMm), intermediate (EMt) and major (EMM). Previous infections were associated with the process in 30% of the cases, administration of drugs also in 30%, and a combination of the two factors in 30% of the subjects. No specific etiology was found in two cases (10%). Respiratory tract symptoms and general discomfort preceded the EMM form, and evidence of digestive organ involvement was frequent in the EMm form. Erythrocyte sedimentation rate was usually high. Postinflammatory sequelae occurred in only two cases, and one subject died in the first 24 hours.
Key words: Erythema multiforme. Toxic epidermal necrolysis. Stevens-Johnson syndrome.
Allergol et Immunopathol 1998;26:283-7.
INTRODUCTION
Erythema multiforme (EM) is an acute mucocutaneous syndrome of self-limited course, with a range of etiologies and a broad spectrum of clinical presentations and severity (1). The first description was by Hebra in 1866 (2, 3). Since then, the symptomatology has been considerably broadened. Three forms of presentation can be distinguished: EMm (minor), EMM (major) and EMt (intermediate). Cases that do not meet the criteria of either EMm or EMM are considered EMt (table I). The term EMM covers the Stevens-Johnson syndrome and toxic epidermal necrolysis (Lyell''s syndrome); the latter is the more severe form of presentation, characterized by the Nikolsky sign (detachment of the epidermal layer of the skin), and can represent a mortality rate as high as 30%. The difference between these two forms of EMM lies only in the inflammatory response. The most frequently associated etiological agents, according to the literature (table II) are Herpes simplex, Mycoplasma pneumoniae, and the intake of certain drugs (2, 4-6).
Table I | ||
| EMm | EMM | |
| Course | Acute, self-limited, recurrent. | Acute, self-limited. |
| Duration | 1-4 weeks. | 1-6 weeks. |
| Lesions | Maculo-erythematous, lesions, blisters, target or "iris" lesions, acral lesions; symmetrical. | Maculo-erythematous, lesions, blisters, detachment of epidermis, symmetrical and disseminated. |
| Mucosa | Not affected; at most, oral mucosa. | Grave; two or more mucosa affected. |
| Sequelae | Post-inflammatry hyperpigmentation. | Hyperpigmentation, scars, synechiae, impaired vision. |
Table II | |
| 1. Infections: | Herpes simplex |
| Mycoplasma pneumoniae | |
| Infectious mononucleosis | |
| Yersinia enterocolitica | |
| TBC | |
| histoplasmosis | |
| 2. Drugs: | Sulphonamides |
| Penicillin | |
| Hydantoins | |
| Phenylbutazone | |
| Barbiturates | |
| 3. Others: | Immunization or desensitization maneuvers |
| Neoplasias | |
| Tumor irradiation | |
| Lupus erythematosus | |
| Sarcoidosis | |
| (Only well-documented causes are listed). | |
PATIENTS AND METHODS
We performed a descriptive study of EM in the pediatrics service of the Hospital Clinic i Provincial in Barcelona (HCP).
First we identified all patients admitted in the pediatrics service and discharged with a diagnosis of EM over the past fifteen years. We used computerized data from the last two years referring to discharged patients, and in earlier cases we used the written records. All discharged patients were coded according to the WHO classification.
We then reviewed all the clinical histories of these patients, excluding those for whom the data were insufficient to corroborate diagnosis (table I). Of 28 subjects initially included, eight were omitted.
The variables analyzed were: age, sex, personal history, etiological factors, prodromes, reason for visit, physical examination, complementary examinations, treatment, complications, mean hospital stay, sequelae and number of relapses.
For statistical treatment of the data we used the SPSS statistical package.
RESULTS
Of the twenty patients, sixteen were male, and four female (ratio 4:1). Mean age was 6.5 years (± 2.09): EMM was diagnosed in nine patients, EMt in four, and EMm in seven (Figs. 1 and 2). There was no seasonal predominance (Fig. 3). Only two patients (10%) did not present related etiological factors in previous weeks. As regards clinical history, 30% presented drug intake, 30% infections, and 30% a combination of the two factors (table III) and (Fig. 4). Respiratory processes were the predominant type of infection. Of the drugs administered, the most frequently associated were sulphonamides, acetylsalicylic acid and penicillin G. No cases of EMm were associated with sulphonamides or penicillin G.
Figure 1.--Forms of EM.
Figure 2.--Sex.
Figure 3.--Seasonal incidence.
Figure 4.--Etiology.
Table III | |||
| EMm | EMt | EMM | |
| DRUGS | |||
| Acetylsalicylic acid (ASA) | 1 | | 1 |
| Phenylbutazone | 1 | | |
| Ampicillin | 1 | | |
| Sulphonamides | | 1 | |
| Erythromycin + sulphonamides + ASA | | | 1 |
| INFECTIONS | |||
| Labial herpes simplex | 1 | | |
| Rhinoadenoiditis | 1 | | |
| Tonsillitis | 1 | | |
| Oral thrush | 1 | | |
| Urinary infection | | 1 | |
| Sinusitis | | 1 | |
| MIXED | |||
| Barbiturates + respiratory infection | | | 1 |
| Sulphonamides + ASA + respiratory infection | | | 1 |
| Sulphonamides + tonsillitis | | 1 | |
| Penicillin G + paratiditis | | | 1 |
| Penicillin G + cefotaxime + cloxacillin + pneumonia | | | 1 |
| Penicillin G + tonsillitis | | | 1 |
Forty-three percent of the cases of EMm presented a history of suspicious food intake: this feature was absent in the other forms (p = 0.037). All patients with EMM presented fever, compared with 50% of those with EMt and 43% of those with EMm (p = 0.029). Fifty-five percent of the patients with EMM presented coughing, a symptom absent in EMt and EMm (p = 0.017). Abdominal pain was more frequent in EMm (43%) and EMt (22%) than in EMM (0%). Eleven percent of the patients with EMM presented pruritus, compared with 43% in EMm and 75% in EMt. Of the EMm patients, 57% presented vomiting and 43% abdominal pain (table IV).
Table IV | ||||
| EMm | EMt | EMM | ||
| SYMPTOMS | ||||
| Fever | 3 | 2 | 9 | |
| Arthralgia | 2 | 0 | 2 | |
| Cough | 0 | 0 | 5 | |
| Vomiting | 4 | 0 | 2 | |
| Diarrhea | 1 | 0 | 1 | |
| Pruritus | 3 | 3 | 1 | |
| Abdominal pain | 3 | 1 | 0 | |
Pneumonia was diagnosed in three patients with EMM, two clinically and radiologically, and one by necropsy; serological studies for influenza (1/256) were obtained only in the last case (the second sample could not be obtained). In one of the patients with EMt, maxillary sinusitis was found by x-ray. In another patient, also with EMt, leukocyturia was observed (> 100 leukocytes per field). Only in one case of EMM was a skin biopsy required to corroborate the clinical diagnosis of EM. In 35% an alteration in the liver function or hepatomegaly was found, with no significant differences between the three series. VSG was also high in 66% of the patients with EMM, 25% of those with EMt and 14% of those with EMm.
During hospitalization antibiotic treatment was administered to two EMm patients, one patients with EMt and six with EMM. All patients in whom EMt or EMM was diagnosed received parenteral corticotherapy, at doses of 1-2 mg/Kg/day, from admission until stabilization or improvement of the clinical picture; the dose was then decreased. Only two patients with EMM were transferred to the ICU; one died within the first 24 hours of respiratory complications. Mean hospital stay was 11.42 days (± 2.4) in EMm, 10.75 (± 3.3) in EMt and 20.4 (± 4.5) in EMM.
Five of the twenty patients had previously presented outbreaks of EM. EMM was diagnosed in only one of these cases; a form of EMt was diagnosed in another, and EMm in the other three (one of whom presented labial herpes). In three of these patients the current outbreak was the third recurrence. Only two EMM patients presented residual pigmentation.
DISCUSSION
This study presents the first descriptive analysis of EM. Obviously the small size of the sample introduces a number of limitations.
The diagnosis of EM was based above all on clinical data (table I) (4). Complementary explorations, such as skin biopsy, cultures, and direct immunofluorescence (2, 6-8) were used when diagnosis is doubtful.
It is occasionally difficult to identify a single etiological agent, since a vast range of factors have been reported in the literature as possible causes (2, 5, 9-13). Correct identification requires an extremely detailed clinical history.
In this study, the drugs most frequently associated with the illness were sulphonamides, penicillin G and acetylsalicylic acid. The first two were not associated with EMm.
In EMM, respiratory symptomatology predominates, with coughing and fever on the days prior to admission; in EMm digestive symptomatology is the most frequent, with vomiting and abdominal pain, coinciding with the appearance of mucocutaneous lesions. These results coincide with those of most authors, in that EMM is usually associated to a larger extent with infections of a respiratory nature or with drug intake, presenting prodromes and general discomfort.
No seasonal predominance was established, a finding that corroborates recent reports in the literature (6). In the past, the illness was believed to be more prevalent in spring and autumn (2).
Even though the role of host immunity in the pathogenesis of EM has been analyzed (14, 15), it is currently difficult to single out any one mechanism, since the results obtained in both immunological and pathological studies are controversial (6). Recently, several authors have reported a strong association between HLA-DW3 and EM (6, 16, 17), which suggest a relationship between the altered immune response and the HLA system (especially in the subjects who present recurrent episodes).
Treatment of EM depends on the causes of the illness and on the severity of the clinical picture. In general, EMm requires symptomatic treatment, only. Recurrences of EM tend to be mainly outbreaks of EMm, related to Herpes simplex, although this herpes is not always identified clinically. Bateman was the first to report the association between Herpes simple and EM, in 1813 (16, 18). Today, patients with recurrent EM are usually treated with aciclovir administered orally for a period of six to eighteen months, since it has been shown to limit recurrence (2, 4-6, 15, 19) even when there is no clinical evidence of herpes. In this study we also observed that recurrences were more frequent in EMm, and found a statistically significant relationship between fever, respiratory symptomatology and EMM. The use of corticoids has generated considerable controversy, since some authors hold that they cause further complications (4) while others recommend them (20) on the grounds that at high doses they suppress the active phase of the illness in the early stages and its complications later on. Our experience, and that of the dermatology department at our hospital, leads us to support the latter view.
Some authors have suggested treatment with cyclosporine in cases of severe, resistant EM (21). Others have obtained positive results with cimetidine used to treat recurrent EM resistant to aciclovir (22). However, there is little experience to date with these drugs.
It is essential that the patient''s family be informed of the possibility of recurrence and of the importance of follow-up at the same center to ensure appropriate study and treatment.
RESUMEN
Se realiza un estudio retrospectivo de 20 niños diagnosticados de eritema multiforme (EM). El diagnóstico se realizó desde el punto de vista clínico, dividiéndose en las formas major (EMM), intermedia (EMt) y minor (EMm). La relación varón/hembra fue 4/1. Sólo dos casos no presentaron factores etiológicos desencadenantes (10%), los 18 restantes tuvieron como antecedentes infecciones (30%), fármacos (30%), o los dos factores a la vez (30%). Se observó el predominio de pródromos con sintomatología respiratoria y malestar general en las formas de EMM, así como sintomatología digestiva en las formas de EMm. Presentaron hepatomegalia o alteración de pruebas hepáticas un 35% de los pacientes. El dato analítico alterado con mayor frecuencia fue la VSG. Sólo hubo secuelas leves (pigmentación residual) en dos pacientes y uno presentó evolución fatal.
Palabras clave: Eritema multiforme. Necrólisis epidérmica tóxica. Síndrome de Stevens-Johnson.
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Correspondence:
Dra. M. A. Martín Mateos
Hospital San Juan de Dios
Sección de Inmunología y Alergia
Paseo San Juan de Dios, 2
08950 Esplugues de Llobregat
Barcelona
