Reactive Infectious Mucosal-predominant Eruption (RIME)

RIME (sometimes known as Mycoplasma-Induced Rash and Mucositis (MIRM)) is a relatively newly described entity, which is a reactive process that occurs in the setting of infection with Mycoplasma pneumoniae (a common bacterial cause of community-acquired pneumonia) or other infections. It usually affects children. It is characterized by severe mucositis (inflammation of mucosa, such as the mouth and eyes) with generally mild/limited skin involvement. Virtually all patients have oral involvement presenting as hemorrhagic crusts and erosions on the lips, tongue and buccal mucosa. The majority of cases will also have bilateral conjuctivitis and ∼60% have urogenital involvement. The skin is usually less involved and the appearance of the rash is variable, with the most common presentation being vesicles and blisters. Since the clinical picture can be very similar to that of Stevens-Johnson syndrome/toxic epidermal necrolysis  (see Ch. 11), patients are usually best assessed in an acute care setting to rule this out. Treatment of severe cases includes systemic steroids and consideration of medication with anti TNF activity such as etanercept or cyclosporine for a few doses. Oral care can involve use of “magic mouthwash” (combination of topical anesthetic, corticosteroid, antibiotic and antacid) and saline soaks followed by petroleum jelly to crusts/erosions. Patients often require referral to ophthalmology and/or urology or gynaecology. Antibiotics covering M.pneumoniae (e.g. macrolides such as azithromycin) may be used but it is unclear if this shortens the course of mucositis and rash. RIME can recur with future infections.

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