To the Editor, Erythema multiforme (EM) is a type of dermatosis That OCCURS as a hypersensitivity reaction in response to medications or infections. Erythema multiforme is mostly Associated With The herpes simplex virus (HSV) or mycoplasma infections, 1-but it is rare EM That is the Epstein Barr Associated With Virus (EBV). We report on an 11-year-old male patient to our hospital ADMITTED With redness, swelling, burning sensation, an itchy rash on hands and feet, and a rash on the body That HAD Begun four days with previously. The patient Suffered fever, sore throat and running a day donot Before These complaints Manifested. The skin rash Began on the sole of the right foot, Which was noticed upon a sensation of something stuck on the right sole, and then a spread to the left sole and the hands. At the outset, the skin rash was pinhead sized, then a Increased in size, and swelling in the hands and feet occurred. Consulted The first physician wrote a prescription for cefuroxime, cetirizine and feniramine. However, the patient’s complaints Were not resolved after one day of using esta medication, and so I was Referred to our hospital. In our physical examination of the patient, to maculopapuler That included rash desquamation Which regions paled under pressure, was Observed on Both palms, soles, arms and legs. His body temperature was 37 ° C. Other system examinations revealed no abnormal findings (Figure 1, Figure 2). Face, body and Mucosal Involvement was not noted.
Figure 1. A red-purple dispersed colored maculopapular rash That pales under pressure was shown around ankle and medial side of the foot. Figure 2. Red-purple erythematous maculopapular lesions colored show desquamation That Were seen in patches on bilateral palmar regions. Laboratory examination revealed leukocyte count: 9900 / mm3, hemoglobin: 14. 1 g / dl, platelet count: 214,000 / mm3, erythrocyte sedimentation rate: 22mm / hour, urea: 32mg / dl, creatinine: 0. 8mg / dl, serum sodium: 134 MEq / L, potassium: 4. 5 mEq / L, AST 31 IU / L, ALT: 22 IU / L. The patient was Also tested for the Rickettsia IgG, HSV type I IgM, HSV type II IgM, EBV VCA IgM, CMV IgM, the Parvovirus IgM, and Mycoplasma pneumoniae IgM antibodies in order to rule out rickettsial diseases and other infectious skin eruptions Because of the symmetrical maculopapular rash Involving the Hands and Feet. Doxycycline treatment was subsequently Initiated with a presumptive clinical diagnosis of rickettsial diseases. On the second day following the patient’s admission to hospital, Appeared typical target lesions, the largest of Which was 2cm in diameter, on the proximal Both thighs and area of the forearms (Figure 3). EBV VCA IgM and IgG Rickettsia Were positive at a titer of 1/10 and 1/64 respectively. Repeated tests in the week and one Performed one month later, there was no Increase in the Rickettsia IgG titres.
Doxycycline treatment was halted on day seven, and EBV infection was thought to be responsible for EM in our patient. Other viral markers and examinations for mycoplasma Were found to be negative. On the fifth day of admission, the patient was discharged from the hospital as the rash had a tendency to pale. The rash Disappeared on the 14th day from the beginning and the patient was cured without sequela. Figure 3. Were Dispersed target lesions shown on the proximal part of the fore arm. One month later, in order to rule out a possible adverse drug reaction due to cefuroxime Reported use in the patient’s history, a patch test (10 mg / ml) was done, Which came out negative. Then a prick test and an intradermal test using cefuroxime Were applied. These tests since turned out negative Also, an oral provocation test was Performed using cefuroxime, Which turned out negative too. Erythema multiforme is acute, self-limited and Usually at times life threatening dermatosis With Which May multiforme lesions present. They include multiple, symmetric, persistent macules, papules, vesicles, and bullae. What has pathognomonic for erythema multiforme Become is the so-called iris or targetoid lesions, plaques Representing center of duskiness in expanding erythematous macules and papules. Commonly Involved areas are extensor surfaces: the palms, the soles, and sites of trauma.
1 The appearance of the rash in our patient shortly after pricking Caused us to think That trauma played a role in esta Facilitating case. In MS, aetiology of herpes simplex mostly Consist and mycoplasma. Medications and some vaccines Also Participate in the aetiology, but in half of the cases an underlying cause can not be found. 2 EBV VCA IgM, tested in our patient was found to be positive. Erythema multiforme occurring EBV infection is Dramatically During rare. 2,3,4,5,6 Certain it is not, Although, the pathophysiological mechanism for the EBV-related MS is thought to be immunocomplex mediated. 4 Hughes et al. Demonstrated perivascular IgM and C3 deposition in direct immunofluorescent examination. 2 In Addition, Carrera et al. Investigated the presence of specific gene sequence of EBV and Herpes simplex by PCR in a tissue biopsy of a Case with cholestatic hepatitis and acute MS; however the result was negative. 5 On the other hand, Chen et al. detected an EBV specific gene sequence in two cases by 32 EM PCR.
6 Due to a lack of the facilities for investigating EBV in tissue With PCR, since we clinically diagnosed MS, and Also for ethical issues, we did not perform a tissue biopsy in our patient. It is well Known viral infections During That, drug-related allergic reactions Rashes increase. 7 related to infectious mononucleosis are aminopenicillins During Often seen; however, serious cutaneous lesions: such as MS and Stevens Johnson Syndrome (SJS) are rare. 8 Our patient was EVALUATED for cephalosporin-related drug reaction due to previous cefuroxime use, but skin tests and oral provocation test results came out negative. Delgado et al. Reported a case of MS due to aminopenicillin use EBV infection. 8 During Contrary to our patient, They found a positive patch test and a delayed reading of an intradermal test Performed for an evaluation of drug sensitivity. They Claimed That cell-mediated hypersensitivity was responsible for the development of drug-related MS. In research Conducted by Jappe, WHO EVALUATED 41 Patients With drug eruptions following the intake of amino-penicillins, 20% of Patients had a florid infectious mononucleosis at the time of the drug eruption. 9 In our case, in terms of explaining aetiology, EBV was determined to infection and an evaluation was made due to drug allergy to cefuroxime in light of Existing Knowledge About virus-drug interaction, and the result was determined to be negative to. 80% of erythema multiforme is classified as minor, is postinfectious Usually, the skin and Primarily Affects more than one and no mucosal surface. 1 It is thought That there is a relationship Between the severity of the disease and factors in aetiology That exist. While viral infections cause erythema multiforme minor Usually and major, medications cause SJS Which progresses with a more serious clinical course.
10 Our patient was diagnosed as erythema multiforme minor, Because there was no mucosal Involvement. The drug allergy tests Were case of the negative and the viral infection was mostly related EM Encountered in minor form. Consequently, our patient was diagnosed as EBV related MS. The prognosis is quite good in EM minor, and it can be cured without sequela in 2-4weeks by Eliminating the triggering cause or by treatment of the underlying infection. Progression to SJS does not Occur In These Cases. Our patient was closely for six weeks Monitored With only the first five days in hospital, and it was Observed That His injuries healed completely. As a result, even though HSV is the MOST Observed of viral infections in the aetiology MS, EBV Might be a rare but a causative factor. Corresponding author. drpinar1975@hotmail. com