CORRESPONDENCE
169 ActaDV ActaDV
Advances in dermatology and venereology Acta Dermato-Venereologica
Differential Diagnosis of Erythema Multiforme in Childhood : A Comment to Siedner-Weintraub et al .
Gregorio P . MILANI 1 , Sebastiano A . G . LAVA 2 , 3 and Mario G . BIANCHETTI 2
1
Pediatric Unit , Foundation IRCCS Ca ’ Granda , Ospedale Maggiore Policlinico , via della Commenda 9 , IT-20122 Milan , and Department of Clinical Sciences and Community Health , Università degli Studi di Milano , Milan , Italy , 2 Pediatric Department of Southern Switzerland , Bellinzona , and Università della Svizzera Italiana , Lugano , and 3 Department of Pediatrics , University Children ’ s Hospital of Bern , Inselspital , Bern , Switzerland . E-mail : milani . gregoriop @ gmail . com
We read with interest the report by Siedner-Weintraub et al . ( 1 ), who found that only 30 out of 119 children with an initial diagnosis of erythema multiforme ( EM ) ( 20 girls , 10 boys , age range 4 – 18 years ) met the Bastuji-Garin classification criteria recommended for diagnosis of this condition . Of the initially misdiagnosed cases , 59 had a non-specific eruption , 29 had features consistent with urticaria multiforme and 2 had acute haemorrhagic oedema of young children . Stimulated by this report , we re-evaluated the characteristics of 35 Swiss children with an initial diagnosis of EM ( 2 – 4 ). The diagnosis of EM was confirmed in only 18 cases ( 12 girls , 6 boys , age range 4 – 13 years ). Of the 17 initially misdiagnosed cases , urticaria multiforme was diagnosed in 8 cases ( 3 girls , 5 boys , age
Reply to the Comment by G . P . Milani et al . range 4 months to 12 years ), acute haemorrhagic oedema of young children in 6 cases ( 2 girls , 4 boys , age range 2 – 19 months ), and non-specific eruption in the remaining 3 cases ( 2 boys , 1 girl , age range 3 months to 13 years ).
In conclusion , EM exclusively affects children ≥ 4 years of age . Furthermore , acute haemorrhagic oedema of young children is often misdiagnosed either as EM or as non-specific eruption . Diagnosis of acute haemorrhagic oedema is made clinically in children ≤ 24 months of age , who do not appear ill , who present : ( i ) with targetoid lesions predominantly over the cheeks , ears and extremities ( with relative sparing of the trunk ), ( ii ) often tender non-pitting oedema of the face , auricles , and extremities , and ( iii ) without pruritus .
Yael SIEDNER-WEINTRAUB 1 and Vered MOLHO-PESSACH 2
1
Pediatric Clinic , Kupat Cholim Meuhedet , and 2 Department of Dermatology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel . E-mail : weinyael @ gmail . com 1 . Siedner-Weintraub Y , Gross I , David A , Reif S , Molho-Pessach V . Paediatric erythema multiforme : epidemiological , clinical and laboratory characteristics . Acta Derm Venereol 2017 ; 97 : 489 – 492 .
2 . Villiger RM , von Vigier RO , Ramelli GP , Hassink RI , Bianchetti MG . Precipitants in 42 cases of erythema multiforme . Eur J
REFERENCES ( for both papers )
Our study re-examined cases of paediatric erythema multiforme ( EM ) in our tertiary medical centre , in order to better characterize this condition in children ( 1 ). Of 119 children given a diagnosis of EM , only 30 met clinical criteria and were included in the study . Mean age was 11.3 years and no cases were identified in children younger than 4 years of age . Common misdiagnoses were urticaria multiforme , non-specific eruptions , and acute haemorrhagic oedema of infancy . Unlike in adults , herpes simplex virus was not a common pathogen , while the most common infectious agent identified was Mycoplasma pneumoniae , suggesting that cases associated with this infection may represent the recent entity , mycoplasma-induced rash and mucositis ( 1 ).
These findings are further confirmed by Milani et al .’ s correspondence . On re-evaluating their own cases of paediatric EM , Milani et al . were able to ascertain the diagnosis of EM in only 18 out of 35 children . Children with EM were older than 4 years of age and misdiagnoses similar to those observed in our study were identified .
Based on both studies , it appears that EM does not exist in infants and toddlers . We suggest that when targetoid lesions are observed in this age group , other diagnoses should be considered , mainly urticaria multiforme and acute haemorrhagic oedema of infancy .
Pediatr 1999 ; 158 : 929 – 932 . 3 . Bianchetti MG . Quiz FMH 60 . Paediatrica 2015 ; 26 : 46 – 47 . 4 . Ferrarini A , Benetti C , Camozzi P , Ostini A , Simonetti GD , Milani GP , Bianchetti MG , Lava SAG . Acute hemorrhagic edema of young children : a prospective case series . Eur J Pediatr 2016 ; 175 : 557 – 561 .
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2018 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2785 Acta Derm Venereol 2018 ; 98 : 169