Abstract

A 62-year-old male presented with an eight-day history of a progressive cutaneous eruption three days after amoxicillin administration for a sinus infection. On physical examination, there were red, atypical targetoid papules with central erosions coalescing into thin plaques on the trunk, extremities, and face. Multiple erosions were observed on the upper and lower mucosal lips with sparing of the tongue and buccal mucosa. A punch biopsy of the left back demonstrated vacuolar alteration of the dermo-epidermal junction and dyskeratotic keratinocytes at all levels of the epidermis and follicular epithelium. HSV and VZV immunohistochemistry and direct immunofluorescence biopsy were negative. An infectious workup was notable for a positive Ebstein Barr virus (EBV) by PCR. He was diagnosed with reactive infectious mucocutaneous eruption (RIME) secondary to EBV infection despite his atypical age. He was started on IVIG and oral prednisone with gradual improvement of his symptoms. RIME is a post-infectious mucocutaneous eruption accompanied by mucositis and cutaneous vesiculobullous lesions that primarily affects children and young patients (mean age 12 years), more commonly males. The histopathology of RIME is similar to Stevens-Johnson syndrome highlighting the importance of clinicopathologic correlation especially in atypical manifestations, such as in our patient’s case.