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Erythema multiforme (EM), an immune-mediated skin condition, can occur after infection or following the use of medications. In this study, we describe a patient who developed EM after nirmatrelvir/ritonavir administration. An 81-year-old woman presented with fever and dyspnea. Laboratory investigations showed positive coronavirus disease (COVID-19) based on polymerase chain reaction assay, and she received a 5-day regimen of nirmatrelvir/ritonavir. We observed development of EM after this treatment and initiated prednisone (1 mg/kg) therapy, which led to rapid improvement. Our study is the first to report EM in a patient with COVID-19, who received nirmatrelvir/ritonavir and showed a favorable response.

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El Eritema multiforme (EM) o eritema polimorfo es una enfermedad aguda de la piel de naturaleza inmunológica con o sin compromiso de mucosas, que puede comportarse como crónica recurrente. Se presenta con lesiones cutáneas en diana distintivas, a menudo acompañado de úlceras o bullas en mucosas (oral, genital u ocular). Entre sus formas clínicas se distingue: una forma menor caracterizado por un síndrome cutáneo leve y su forma mayor que se manifiesta como una afectación cutánea con daño mucoso marcado. Entre sus principales diagnósticos diferenciales se encuentran el Síndrome de Stevens-Johnson (SSJ) y Síndrome de Lyell (Necrólisis epidérmica tóxica (NET)). Tiene una incidencia estimada < 1%, siendo su forma mayor levemente más frecuente que su forma menor (0.8-6 por millón/año). Puede darse a cualquier edad, presentando un peak de incidencia entre los 20 y 30 años, predominando ligeramente el sexo masculino con una proporción 3:2, sin predilección racial. Su presentación en edad pediátrica es rara, más aún en la primera infancia. En esta población es más frecuente el EM menor recurrente. En el presente texto se reporta un caso de EM en población pediátrica como una rara forma de presentación exantemática, abordado en el Servicio de Pediatría del Complejo Asistencial Dr Victor Rios Ruiz (CAVRR)en la ciudad de Los Ángeles, Chile en el presente año.

Erythema multiforme (EM) also known as polymorph erythema is an acute skin disease of immunological nature with or without mucous membrane involvement, which may behave as chronic recurrent. It presents with distinctive targets like skin lesions, often together with ulcers or bullae in mucous membranes (oral, genital or ocular). Among its clinical forms are: a minor form characterized by a mild skin syndrome and its major form that manifests as a skin disease with marked mucosal damage. Among its main differential diagnoses are Stevens-Johnson Syndrome (SJS) and Lyell Syndrome (Toxic Epidermal Necrolysis (TEC)). It has an estimated incidence < 1%, with its major form being slightly more frequent than its minor form (0. 8-6 per million/year). It can occur at any age, presenting a peak incidence at the age between 20 and 30 years, with a slight predominance of males with a 3:2 ratio, without racial predilection. Its presentation in pediatric age is rare, even more so in early childhood. Minor recurrent EM is more common in this population. This paper reports a case of EM in the pediatric population as a rare form of exanthematic presentation, addressed at the Department of Pediatrics of the Complejo Asistencial Victor Rios Ruiz (CAVRR) in the city of Los Angeles, Chile this year.

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INTRODUCTION: Erythema multiforme (EM) is a reactive mucocutaneous disorder typically initiated by viral infections. Although the management of EM differs according to the clinical course and trigger factor, it is not clear whether antiviral suppressive therapies may be useful in cases related to such infections. Moreover, the treatment is most often based on supportive care directed towards only the symptoms. AIM: To present a clinical case of a child in which antimicrobial photodynamic therapy (aPDT) and photobiomodulation therapy (PBMT) were used for orofacial manifestations of EM secondary to viral infections. CASE REPORT: A Brazilian 1-year-old boy was admitted to an ICU due to a severe Influenza A H3N2 infection, pneumonia with pleural effusion, and sepsis. About 10 days later, it was noted bleeding lip lesions covered by crusts and bleeding tongue lesions, diagnosed as EM secondary to both H3N2 and herpes simplex virus infections, confirmed by serology tests. A combination of an aPDT session and six PBMT sessions was proposed and resulted in almost complete resolution of the lesion on the 7th day. CONCLUSION: Given the complexity of the present case, the combination of phototherapies seems to be a promising tool for treating acute orofacial mucosal lesions of viruses-induced EM. More studies, however, are needed to reach a definite conclusion.

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OBJECTIVE: The aim of this study was to evaluate the coronavirus disease 2019 (COVID-19) cutaneous manifestations described in pediatric patients and discuss their relevance for early diagnosis. DATA SOURCE: The study consisted of a systematic review of original articles indexed in PubMed and Embase databases, as well as gray literature articles found through Google Scholar. A search strategy, based on PICO (Patient, Intervention, Comparison, Outcome) Tool, with the terms "child," "infant," "childhood," "adolescents," "teenagers," "COVID-19," "SARS-CoV-2," and "skin manifestations," was performed to optimize the findings. The study did not restrict any article regarding language. DATA SYNTHESIS: Out of the 310 articles that initially met the inclusion criteria, 35 were selected for review, totalizing 369 patients. The most common COVID-19 cutaneous manifestations in children and adolescents were Chilblain-like lesions, presented in 67.5% of the cases, followed by erythema multiforme-like (31.7%) and varicella-like lesions (0.8%). The Chilblain-like lesions appeared 7.6 days (95%CI 7.4-7.8) after the viral infection and lasted for 17.5 days (95%CI 16.5-18.5), erythema multiforme-like lesions appeared in 9.5 days (95%CI 9-10) and lasted for 10.3 days (95%CI 9.1-11.5), and varicella-like lesions appeared in 12.3 days (95%CI 4-20.6) and lasted for 7 days. CONCLUSIONS: Knowledge of the different skin manifestations in children and adolescents with COVID-19 is essential for an early diagnosis and, consequently, the possibility of promptly care adoption as well as to interrupt the new coronavirus transmission chains in the current pandemic context.

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RESUMEN: El eritema multiforme es una enfermedad autoinmune vesicular-ampollosa y autolimitada, se presenta de forma aguda afectando la piel y mucosa. En 2015, Lee E. y Freer J., incluyeron esta enfermedad dentro de los síndromes dermatológicos paraneoplásicos, pero actualmente no existen muchas publicaciones de esta entidad como manifestación a una neoplasia subyacente. El objetivo de esta investigación es presentar el eritema multiforme como una manifestación paraneoplásica inusual. En este caso una paciente de 64 años de edad que cursaba con adenocarcinoma de colon exhibió el eritema multiforme oral; cuyas manifestaciones bucales involucionaron gracias a la farmacoterapia local y sistémica en conjunto con la excéresis de la lesión cancerosa en el colon. Es importante reconocer la presencia de eritema multiforme como una manifestación paraneoplásica cuando no se exhiben los factores etiológicos frecuentes de esta patología y, por lo tanto, centrarse en la búsqueda subyacente de neoplasias malignas que no son muy evidentes.

ABSTRACT: Erythema multiforme is a self-limiting, blistering, autoimmune disease that presents acutely, affecting the skin and mucosa. In 2015, Lee E. and Freer J. included this disease in paraneoplastic dermatological syndromes, but there are currently not many publications about this entity as a manifestation of an underlying malignancy. The objective of this research is to present the erythema multiforme as an unusual paraneoplastic manifestation. In this case, a female 64-year-old patient with colon adenocarcinoma exhibited oral multiform erythema; whose oral manifestations regressed thanks to local and systemic pharmacotherapy in conjunction with the exeresis of the cancerous lesion in the colon. It is important to recognize the presence of erythema multiforme as a paraneoplastic manifestation when the frequent etiological factors of this pathology are not exhibited and, therefore, to focus on the underlying search for malignant neoplasms that are not very evident.

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Oral mucosa could be the first site infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ­the causative agent of coronavirus disease 2019 (COVID-19). Indeed, different oral and paraoral lesions, conditions and symptoms have been reported in patients with COVID-19. Experts thought that such oral lesions could be secondary to the COVID-19-associated deterioration of systemic health or due to treatments of COVID-19. We present here a case of a 24-year-old male presented with painful multiple ulcers involving the labial and buccal mucosae bilaterally after a while of feeling very mild symptoms that laboratory-confirmed by reverse-transcription polymerase chain reaction to be COVID-19. Involvement of eyes was also reported. The above clinical presentation was consistent with minor erythema multiform. Many topical preparations were prescribed but with limited improvement. Hence, oral prednisolone was prescribed with a 40-mg loading dose that was tapered by 10 mg every 3 days. Complete healing of oral mucosa was observed on the 10 day. Strikingly, the patient got affected with the second episode of similar oral lesions 5 months later without any apparent triggering factors, suggestive a long term effects of COVID-19 in a subset of patients. The present case report provides dentists with useful information and increases their awareness regarding possible involvement of oral cavity with multiple ulcerative lesions associated with COVID-19 (AU)

A mucosa oral pode ser o primeiro local infectado com a síndrome respiratória aguda grave coronavírus 2 (SARS- CoV-2) ­ o agente causador da doença por coronavírus 2019 (COVID-19). De fato, diferentes lesões, condições e sintomas orais e paraorais foram relatados em pacientes com COVID-19. Os especialistas pensavam que essas lesões orais poderiam ser secundárias à deterioração da saúde sistêmica associada ao COVID-19 ou devido a tratamentos do COVID-19. Apresentamos aqui um caso de um homem de 24 anos que apresentou múltiplas úlceras dolorosas envolvendo bilateralmente as mucosas labial e bucal após um tempo sentindo sintomas muito leves que foram confirmados laboratorialmente pela reação em cadeia da polimerase de transcrição reversa como COVID-19. O envolvimento dos olhos também foi relatado. A apresentação clínica acima foi compatível com eritema multiforme menor. Muitas preparações tópicas foram prescritas, mas com melhora limitada. Assim, foi prescrito prednisolona oral com uma dose inicial de 40 mg que foi reduzida em 10 mg a cada 3 dias. A cicatrização completa da mucosa oral foi observada no 10º dia. Surpreendentemente, o paciente foi afetado com o segundo episódio de lesões orais semelhantes 5 meses depois, sem nenhum fator desencadeante aparente, sugerindo efeitos de longo prazo do COVID-19 em um subconjunto de pacientes. O presente relato de caso fornece aos dentistas informações úteis e aumenta sua conscientização sobre o possível envolvimento da cavidade oral com múltiplas lesões ulcerativas associadas ao COVID-19 (AU)

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Objetivo: Este trabalho tem como objetivo relatar um caso de Eritema Multiforme (EM) menor desencadeado por amoxicilina oral, tratado a partir de aplicação de laser de baixa intensidade na região afetada pela doença. Relato de caso: Paciente de 12 anos, atendido no Hospital Metropolitano Odilon Behrens (HMOB), apresentando úlceras em mucosa jugal, lábios e língua, disfagia, dislalia e febre, recebeu diagnóstico clínico de EM e tratamento com aplicação de laser vermelho de baixa intensidade, emitindo em 660nm, com potência de 100mW, sendo aplicado uma dose de 33 J/cm², em pontos com distância aproximada de 1 cm entre eles. Houve resolução das lesões em 7 dias após instituição do tratamento. Conclusão: O presente trabalho mostrou que a Terapia de Fotobiomodulação (TF) com laser de baixa intensidade associado à substituição do medicamento detectado como causa foram fundamentais para a resolução do EM, evidenciando as propriedades bioestimulantes do laser nas lesões ulceradas de mucosa bucal.

Aim: This paper aims to report a case of minor Erythema Multiforme (EM) triggered by oral amoxicillin, treated with low-level laser applications in the region affected by the disease. Case report: A 12-year-old patient, treated at the Metropolitan Hospital Odilon Behrens, presenting ulcers in the buccal mucosa, lips, tongue, dysphagia, dyslalia, and fever, received a clinical diagnosis of EM and treatment with low-intensity red laser applications, emitted at 660 nm, with a power of 100 mW, with a dose of 33 J/cm² being applied, in points with an approximate distance of 1 cm between them. The lesions resolved within 7 days after treatment were instituted. Conclusion: This present paper shows a successful therapeutic, non-pharmacological alternative for the management of EM, showing the bio stimulating properties of laser in ulcerated lesions of the oral mucosa.

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Recurrent erythema multiforme is a chronic relapsing disease that represents a therapeutic challenge. Our objective was to retrospectively evaluate the clinical-epidemiological characteristics and therapeutic response of patients with recurrent erythema multiforme and suggest a therapeutic protocol. We included patients with recurrent erythema multiforme diagnosed between January 2000 and December 2019. Clinical symptoms and a positive serology for herpes simplex virus were the inclusion criteria to initiate acyclovir in monotherapy or a combined treatment with dapsone, thalidomide, or immunosuppressants in refractory cases. Thirty-five patients were included and 71.4% were female. The median disease onset age was 35.7 years and the mean follow-up was 7.58 years. The skin was the most affected site (91.4%). Herpes simplex virus immunoglobulin (Ig)G serology was positive in 91.1% of cases. Acyclovir treatment was used in 33 of 35 patients, and complete remission was achieved in 22 of 33 after the first therapeutic course; 16 of 22 relapsed and required a second acyclovir cycle. Combined treatment with dapsone was required in nine of 33 due to partial response to acyclovir; thalidomide was an adjuvant drug in four of 33 due to adverse effects to dapsone. After the first cycle of acyclovir with or without combined therapy, 19 of 33 patients relapsed and received 2-6 additional cycles. Our results suggest that recurrent erythema multiforme presents a good response to acyclovir in monotherapy or in combined therapy with dapsone or thalidomide in the majority of patients. We propose a long-term therapeutic protocol to enable disease remission.

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Erythema multiforme (EM) is a mucocutaneous condition of uncertain etiology, although the hypersensitivity reaction to a wide variety of agents may be related to the onset of the lesions. In about half of the affected patients it is possible to identify a previous infection. This article aims to report a case of EM in the oralmucosa after qHPV vaccine (Gardasil®), to highlight the diagnostic process and the proposed treatment. Female patient, 16 years old, after 10 days of receiving the first dose of the qHPV vaccine. On physical examination, she presented multiple ulcers and hemorrhagic crusts to the touch, based on the clinical picture and the history of the disease, a diagnostic hypothesis was EM. Low-level laser therapy (LLLT) was chosen as an alternative treatment, since the exercises applied were not successful. The patient was followed up, reported decreased pain and burn and, after one year of treatment, there was no recurrence of the lesions. Laser treatment showed an effective treatment alternative, in addition to the low cost and ease of application.

El eritema multiforme (EM) es una afección mucocutánea de etiología incierta, aunque la reacción de hipersensibilidad a una amplia variedad de agentes puede estar relacionada con la aparición de las lesiones. En aproximadamente la mitad de los pacientes afectados es posible identificar una infección previa. Este artículo tiene como objetivo informar un caso de EM en la mucosa oral después de la vacuna qHPV (Gardasil®), para resaltar el proceso de diagnóstico y el tratamiento propuesto. Paciente de 16 años, después de 10 días de recibir la primera dosis de la vacuna qHPV. En el examen físico, presentó múltiples úlceras y costras hemorrágicas al tacto, según el cuadro clínico y la historia de la enfermedad, una hipótesis diagnóstica fue EM. La terapia con láser de baja potencia (TLBP) se eligió como un tratamiento alternativo, ya que los ejercicios aplicados no tuvieron éxito. La paciente fue seguida, informó disminución del dolor y las quemaduras y, después de un año de tratamiento, no hubo recurrencia de las lesiones. El tratamiento con láser mostró una alternativa de tratamiento efectivo, además del bajo costo y la facilidad de aplicación.

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Background: Erythema multiforme (EM) is an immune-mediated skin disease which may manifest as cutaneous or mucocutaneous lesions. It is uncommon in horses. EM lesions have a symmetrical bilateral distribution; they are usually urticarial, necrotizing, and, less commonly, ulcerative. In equines, the trigger is usually unknown, and cases are often classified as idiopathic. Diagnosis is based on a thorough history and physical and histopathological examination of lesions. According to the clinical presentation and histopathological characteristics of the cutaneous lesions, this case is the first report to describe diagnosis and treatment of a horse with EM in Brazil. Case: A Quarter Horse filly was followed clinically for 12 months after sudden onset of skin lesions at 18 months of age. The initial lesions were non-alopecic papules with a symmetrical bilateral distribution. Six months after onset, the skin lesions maintained the original distribution pattern; however, they had progressed to papules and plaques with varying annular, arciform, serpiginous, targetoid, or alopecic appearance. At 8 months, the same distribution pattern and appearance remained, but the lesions had become more severe and extensive, with involvement of the labial commissures and perineal region, without any erosions/ulcerations, scaling/crusting, pain, or pruritus. At 12 months, new nodular lesions were found on the medial and lateral surfaces of the hind limbs, neck, bilateral trunk, and root of the tail. The lesions were firm, non-pruritic, and non-tender on palpation. Swabs were obtained from the papular lesions. Skin specimens were also obtained with a 6-mm punch and via incisional biopsy and histological sections were made. Bacterial and fungal cultures were negative. Appropriate stains did not identify fungal structures, were negative for acid-fast bacilli, and did not reveal any metachromatic granules in the sampled cell population. The histopathological findings were characteristic of immune-mediated disease, with a vacuolar interface dermatitis affecting the hair follicles more than the epidermis, necrotic keratinocytes, lymphocyte satellitosis, leukocytoclastic mixed vasculitis of the mid-dermis and deep dermis, and variable granulation tissue, consistent with erythema multiforme and leukocytoclastic vasculitis. Immunosuppressive therapy with corticosteroids and oral supplementation with omega-3 and omega-6 fatty acids and vitamin E were prescribed. After institution of therapy, no new lesions developed, the existing lesions remained stable (though permanent), and hair regrew in the previously alopecic areas. All physiological parameters remained normal throughout the follow-up period. Discussion: Erythema multiforme is rarely reported in horses. According to our literature review, this is the first description of EM in horses in Brazil. EM should be included in the differential diagnosis of horses that present with plaques in a diverse, geographic distribution and a negative initial dermatological screening examination. Further clinical investigation is warranted, with special attention to potential antigenic triggers. A thorough drug and dietary history and close attention to comorbidities are essential, as the suppression of potential culprit factors has important prognostic value and contributes to the elucidation of EM triggers.(AU)

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El síndrome de Rowell se caracteriza por la asociación de lupus eritematoso y lesiones de tipo eritema multiforme, asociado con marcadores inmunológicos como los anticuerpos antinucleares con patrón moteado, anticuerpos anti-La y factor reumatoide positivo. El objetivo de la comunicación es reportar el caso de una mujer de 42 años, con diagnóstico hace años de lupus eritematoso sistémico, últimamente con lesiones tipo eritema multiforme. Presenta anticuerpo antinuclear con patrón moteado y factor reumatoide positivos. Se concluye tratarse de un caso de síndrome de Rowell.

Rowell's syndrome is characterized by the association of lupus erythematosus and erythema multiforme-type lesions, associated with immunological markers such as mottled antinuclear antibodies, anti-La antibodies and positive rheumatoid factor. The objective of the communication is to report the case of a 42-year-old woman, diagnosed years ago with systemic lupus erythematosus, lately with lesions of the erythema multiforme type. He presents antinuclear antibody with a mottled pattern and positive rheumatoid factor. It is concluded to be a case of Rowell's syndrome.

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Rowell's syndrome is characterized by an association of lupus erythematosus and erythema multiforme, with distinctive laboratory findings. Its treatment is similar to lupus. We report a 16-year-old female presenting with skin lesions, laboratory and histology consistent with this entity. Because of the spread of cutaneous involvement and development of epidermal detachment, she required therapy with intravenous corticosteroids and gamma globulin.

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O eritema multiforme é uma doença incomum em cães, que afeta pele e mucosas, cuja etiologia ainda não foi completamente elucidada. Contudo, o envolvimento exclusivo da cavidade oral é considerado raro, tendo sido descrito poucas vezes até o presente momento. O objetivo deste trabalho é descrever um caso de eritema multiforme limitado à cavidade oral em um canino. Um cão, fêmea, Akita, com sete anos de idade, apresentou histórico de ulcerações na cavidade oral e nas laterais da língua, sem alterações cutâneas ou sistêmicas. O diagnóstico definitivo foi realizado por meio do exame histopatológico da mucosa oral, e a terapia imunossupressora empregada mostrou-se eficaz. Embora o eritema multiforme seja considerado incomum na espécie canina, este relato de caso apresenta a forma mais rara da doença, com poucos casos descritos em medicina veterinária.(AU)

Multiforme erythema is an uncommon disease in dogs that affects the skin and mucous membranes, the etiology of which has not yet been fully elucidated. However, the exclusive involvement of the oral cavity is considered rare, having been described few times until the present moment. The aim of this work is to describe a case of multiforme erythema limited to the oral cavity in a canine. A seven-year-old female dog, akita, presented a history of ulcerations in the oral cavity and on the sides of the tongue, with no cutaneous or systemic changes. The definitive diagnosis was made through the histopathological examination of the oral mucosa and the immunosuppressive therapy used proved to be effective. Although multiforme erythema is considered uncommon in the canine species, this case report presents the rarest form of the disease, with few cases described in veterinary medicine.(AU)

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