BACKGROUND Stevens-Johnson syndrome (SJS) is a rare, immune-mediated mucocutaneous disorder usually triggered by medications or infections. It typically manifests with widespread epidermal detachment and mucosal ulcerations, but atypical cases can present with isolated mucosal involvement, leading to diagnostic uncertainty and delayed treatment. Recognizing such varying presentations is crucial to precent progression to more severe disease and improve outcomes. CASE REPORT We present the case of an 18-year-old male with no significant medical history who presented with severe odynophagia, oral ulcerations, conjunctivitis, and dysuria shortly after completing a course of cefdinir for an upper respiratory infection. Notably, he lacked the characteristic diffuse rash seen in classic SJS. Laboratory evaluation revealed elevated inflammatory markers, and imaging demonstrated non-specific soft tissue edema. Initial management included cessation of cefdinir, intravenous fluids, corticosteroids, and broad supportive care. During hospitalization, he developed macular lesions on the palms and soles and progressive mucosal sloughing. Serologic testing later confirmed elevated Mycoplasma pneumoniae IgM and IgG titers, leading to reclassification of this condition to Mycoplasma pneumoniae-associated SJS (MP-SJS). He was treated with intravenous immunoglobin and azithromycin, with gradual improvement and full recovery after a 2-week hospital course. CONCLUSIONS This case highlights an atypical, mucosal-predominant presentation of Mycoplasma pneumoniae-associated SJS in an adolescent male, initially mimicking severe oropharyngeal infection. Clinicians should maintain a high index of suspicion for SJS in patients presenting with acute mucositis and odynophagia following recent medication use or respiratory illness, even when the cutaneous findings are absent. Early identification, withdrawal of the offending agent, and prompt multidisciplinary care are critical to favorable outcomes.

Syphilis is a sexually transmitted infection caused by Treponema pallidum, primarily transmitted by sexual intercourse. Secondary syphilis is characterized by lesions on the skin and mucosal membranes, including condyloma lata (CL), occurring in 17% of secondary syphilis cases. Papules or flat-colored skin plaques are characteristic of CL. They are typically found in humid regions, such as skin folds, including the labia majora, perianal area, axilla, interdigital spaces, and inframammary folds. Presentation in an open region of the body, such as the nipple and the surrounding area of the breast, is rare. Herein we report a case of a 30-year-old female presenting with papules on both breasts and roseola syphilitica with Biett's collarette on both palms and soles that had not been pruritic nor painful for three weeks. The patient has been treated for human immunodeficiency virus (HIV) for the past year. The patient was involved in prostitution for three years, with a total of 6 sexual partners. T. pallidum Hemagglutination Assay (TPHA) and the Venereal Disease Research Laboratory (VDRL) were reactive, with a VDRL titer of 1:8. The patient received a single dose of benzathine penicillin 2.4 million IU injected intramuscularly. The histopathology examination from papules on the breast confirmed the diagnosis of CL, which revealed lymphoplasmacytic infiltrates around the blood vessels and plump endothelial cells. The skin-colored papules on both areolas and the rash associated with secondary syphilis on both palms and soles began to fade two weeks after the intramuscular injection of single dose benzathine penicillin 2.4 million IU. Unusual presentation of secondary syphilis outside predilection sites is possible. A high degree of suspicion is warranted when unusual papules are present, especially with a background of multiple sexually transmitted diseases and immunocompromised condition.

Mycoplasma pneumoniae-induced rash and mucositis (MIRM) is a distinct emerging clinical entity typically affecting adolescents and adults after a respiratory infection from Mycoplasma pneumoniae. Other known mucocutaneous complications include Stevens-Johnson syndrome, erythema multiforme, and toxic epidermal necrolysis. We present the case of a 24-year-old male patient who developed fever and cough followed by a rapidly evolving mucocutaneous syndrome characterized by oral mucositis, bilateral conjunctivitis, and vesiculobullous skin lesions affecting the palms, soles, and trunk with no evidence of skin detachment. These findings meet the proposed diagnostic criteria for MIRM. This case highlights the importance of recognizing MIRM as a distinct diagnostic entity to guide targeted antimicrobial therapy and avoid unnecessary morbidity associated with misdiagnosis and inappropriate treatment. Early differentiation from Steven-Johnson syndrome and toxic epidermal necrolysis is critical for optimal patient outcomes.

Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder which is characterized by pruritus and elevated bile acids during pregnancy and is further coupled with higher maternal and fetal risks. We report a rare case of early-onset, refractory ICP with elevated liver enzymes in a 25-year-old primigravida with a monochorionic diamniotic twin gestation complicated by selective fetal growth restriction (sFGR). At 24 weeks of gestation, the patient presented with severe generalized pruritus, mainly on the palms and soles, impairing her quality of life. The patient with insignificant medical history of liver diseases, but has a significant family history of ICP. On examination, she was afebrile, hemodynamically stable, and without jaundice or rash. Laboratory findings revealed moderately raised bile acids (40.98 µmol/L) fulfilling criteria for moderate ICP but coupled with elevated liver enzymes. Viral hepatitis serologies, autoimmune profile, and abdominal ultrasound were all unremarkable. Treatment with ursodeoxycholic acid (UDCA) 500 mg twice daily was initiated. Given worsening biochemical (doubling of bile acids) and clinical findings, gastroenterologists were consulted after a week of treatment initiation, and their recommendation was to add cholestyramine 4 g once daily as an adjunctive. Afterwards, with persistently elevated bile acids, the UDCA dose increased to 500 mg three times daily, and cholestyramine was increased to 4 g twice daily. Phytonadione (vitamin K) 10 mg orally daily was added to reduce the risk of bleeding due to reduced absorption of fat-soluble vitamins caused by cholestyramine. At 32 weeks of gestation, she developed vomiting, coffee-ground emesis, vaginal spotting, and abdominal pain, progressing to preterm labor with non-reassuring fetal heart tracings. An emergency category 1 cesarean section was performed, delivering two viable female infants (1600 g and 1160 g), both admitted to the neonatal intensive care unit (NICU). Postnatally, the maternal condition was stable, and biochemical parameters normalized rapidly within 72 hours postpartum. Pruritus resolved completely, confirming the diagnosis of ICP.

An investigation team was deployed to determine the cause of an outbreak of a cluster of cases of fever and rash in a public elementary school in Antipolo City, Philippines, after the Public Health Unit was notified on 24 October 2022. The team also aimed to identify the source of the outbreak and to guide prevention measures.

Japanese spotted fever (JSF), caused by Rickettsia japonica, is an endemic tick-borne disease in Japan that usually responds well to tetracycline therapy. However, delayed diagnosis and treatment can result in serious complications such as disseminated intravascular coagulation (DIC) and death. To identify early markers of severe disease, a case series of five JSF patients (one male patient, four female patients; aged 61-78) treated between 2019 and 2024 was analyzed. All patients presented with fever and erythema; two exhibited eschar. Although empirical tetracycline therapy was administered in every case, initiation was delayed in three patients. Among these, two developed DIC, and one experienced multiple organ failure and died despite intensive treatment. Laboratory findings in the fatal case revealed markedly elevated white blood cell (WBC) and creatine kinase (CK) levels at presentation. Statistical analysis (Kruskal-Wallis test) demonstrated significantly higher WBC (p = 0.023) and CK (p = 0.041) values in the fatal case compared with survivors, while platelet count, C-reactive protein, procalcitonin, and liver enzyme levels showed no significant differences. These findings emphasize the importance of early suspicion and prompt antibiotic therapy for JSF, particularly when patients present with fever, rash (including palms and soles), and eschar. Delay in tetracycline initiation correlated with prolonged hospitalization and poor outcomes. Elevated WBC and CK at admission may represent early prognostic indicators for severe JSF, warranting close monitoring and aggressive management. In summary, delayed treatment and high initial WBC and CK were associated with progression to DIC and death in this series. Rapid diagnosis and immediate tetracycline therapy are essential to prevent severe complications.

Mycoplasma-induced rash and mucositis (MIRM), a new distinct entity, demonstrates a unique presentation in contrast to other mucocutaneous eruptions. Its clinical features include prominent mucositis, limited body surface area involvement, and confirmation of infection with Mycoplasma pneumoniae. Despite its infrequency, MIRM demands prompt recognition and management due to its significant morbidity and mortality. A 13-year-old female had been reported with a high fever, mild productive cough, bilateral eyelid swelling, severe conjunctival erythema, eye discharge, a rash on her palms and soles, and mouth mucositis caused by Mycoplasma pneumoniae. Despite initial antibiotic treatment, the patient was not improving, necessitating the administration of intravenous methylprednisolone, which resulted in significant clinical improvement. This case report indicates the significance of investigating Mycoplasma pneumoniae as a possible etiology in patients with blistering skin and mucosal involvement, even in the absence of respiratory symptoms. It also highlights the diagnostic dilemma and significant ocular morbidity associated with MIRM, which necessitated ophthalmological management.

Secondary syphilis can compromise many organs and is widely known for manifesting with classic signs, such as a rash that involves palms and soles along with mucosal lesions. The absence of these manifestations, along with false negative serological tests, as seen with the prozone phenomenon, poses a difficult challenge for the clinician. When skin lesions are visible, a biopsy for pathological description and immunohistochemistry for Treponema pallidum may help aid in the confirmation and certainty of the diagnosis. Here, we report a case of secondary syphilis with atypical manifestations.

A 72-year-old woman presented with fever, generalized rash, including on the palms and soles, arthralgia, facial edema, and hepatic dysfunction. She lived in a rural area and had recent outdoor exposure to farming but no travel history. Physical examination revealed a small erythematous lesion on her right thigh, suspected to be a tick bite, though no eschar was present. Initial serological testing for Rickettsia (R.) japonica using the indirect immunofluorescence assay (IFA) was negative. Due to strong clinical suspicion of Japanese spotted fever, empirical treatment with oral minocycline was started, resulting in rapid resolution of fever and gradual improvement of liver function. A skin biopsy of a rash lesion revealed perivascular lymphohistiocytic infiltration and endothelial swelling, consistent with small-vessel vasculitis. Convalescent-phase serology later confirmed R. japonica infection with a fourfold rise in immunoglobulin G (IgG) titers. The patient fully recovered following a five-day course of minocycline. This case highlights the importance of early clinical diagnosis and empirical treatment in suspected Japanese spotted fever, especially in elderly patients with characteristic systemic symptoms and rural exposure, even when serologic confirmation is initially unavailable. Histopathological findings may support the diagnosis when serology is inconclusive. Prompt recognition and early intervention are essential to avoid complications and improve outcomes.

This case report describes a 21-year-old woman who presented with diffuse, non-pruritic erythematous papules involving the palms, soles, cervical region, inguinal folds, and perineal area. The lesions appeared approximately one month following unprotected sexual contact with a partner with multiple previous sexual relationships. Clinical examination revealed well-demarcated, lenticular papules with fine scaling and generalized non-tender lymphadenopathy, without mucosal erosions or genital ulcers. Serologic testing confirmed the diagnosis of secondary syphilis, with high titers on both treponemal and non-treponemal assays. The patient was treated with a single intramuscular injection of benzathine penicillin G and supportive therapy. Early clinical improvement was observed, and follow-up serological monitoring was arranged. This case emphasizes the importance of recognizing the protean manifestations of secondary syphilis, which may mimic other dermatologic or systemic conditions. Prompt diagnosis through comprehensive history-taking, physical examination, and appropriate serological testing is critical. In addition to treatment, counseling and partner notification are essential components of management to prevent reinfection and curb disease transmission. This report highlights the continued relevance of syphilis in modern clinical practice and underscores the importance of maintaining a high index of suspicion, particularly in young, sexually active individuals presenting with unexplained mucocutaneous lesions.

Syphilis, a sexually transmitted infection caused by Treponema pallidum (T. pallidum), is re-emerging globally. Recent epidemiological data show a rising incidence, particularly among men who have sex with men (MSM). Known as 'the great mimic' for its broad clinical spectrum, secondary syphilis classically presents with a maculopapular rash involving the trunk and extremities. However, it can also present with atypical cutaneous manifestations, especially in immunocompromised patients. This aspect may contribute to delayed diagnosis and treatment. Starting from a clinical case, we will conduct a literature review on syphilis/HIV coinfection, with a particular focus on the broad spectrum of cutaneous manifestations and the key differential diagnoses involved. We report the case of a 60-year-old male living with HIV who presented with non-pruritic, polymorphic skin lesions sparing the palms and soles. The patient had a prior history of treated latent syphilis. Initial diagnostic workup excluded common differentials, including monkeypox and fungal infections. Serologic testing confirmed active syphilis with a reactive Rapid Plasma Reagin (RPR) titer of 1:32, skin biopsy showed dense plasma cell-rich infiltrate, and immunohistochemistry was positive for T. pallidum. Despite negative cerebrospinal fluid findings, neurological symptoms prompted treatment with intravenous penicillin G, and the symptoms resolved with treatment. This case underscores the importance of considering syphilis in the differential diagnosis of atypical dermatologic presentations, given its increasing prevalence and potential for severe systemic involvement.

This report describes the occurrence of toxic shock syndrome in a teenage girl. She presented with fever, rash, vomiting, dyspnoea and drowsiness. Examination showed a strawberry tongue and suppurative lymphadenitis in the right axilla with hypotensive shock. Abdominal examination confirmed hepatomegaly. Laboratory evaluation confirmed sepsis. The clinical presentation and evaluation suggested the possibility of toxic shock syndrome (TSS). Culture of her axillary lymph node abscess was positive for Acinetobacter baumannii The child was managed with supportive therapy including high flow oxygen, fluid resuscitation, inotropes and antibiotics. She recovered within a week and was reviewed 1 week later. She was found to have skin desquamation on her palms and soles. TSS should be considered in the differential diagnosis in a child presenting with fever, rash and hypotension. It requires thorough examination and evaluation to identify the condition and focus of infection and prompt aggressive management which can bring best outcomes.