Introduction
The development of Erythema Multiforme Major subsequent to Mycoplasma Pneumoniae infection is well established in the literature. Despite this, identifying the disease is still a challenge for clinicians and is often confused with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). [1,2] Albeit no form of therapy is eminent as widely effective, the importance of additional case reports are essential for further characteristics of EMM and its management.

Herein, we presents case of a pronounced erythema multiforme major induced by mycoplasma pneumoniae in a pediatric age. The rashes on the skin and mucus layers developed 98 hours after the appearance of the common cold symptoms. Glucocorticoid- therapie led to the full recovery after 3 weeks without any further complications.

Case Report
An ill-appearing, 11-year-old child with a 4-day history of a productive cough, fever and pharyngitis was admitted to our hospital, pediatric emergency room (ER) due to reduced oral intake. Physical examination revealed several pinkish-red target-like lesions over the trunk and upper extremities (Figure 1 B and C), hemorrhagic- exudative plaques on the lips (Figure 1D), gingival bleeding and changes in the oral mucosa. SJS and staphylococcal scalded skin syndrome was excluded with the negative Nikolsky sign. [3-5]

Clinical features, such as cervical lymphadenitis, strawberry tongue or desquamating perineal exanthema was not detected. [6,7] Relevant previous illnesses including herpes simplex virus infections and the intake of suspected drugs causing erythema, such as NSAID’S, certain antibiotics, and anticonvulsants was denied. [8]

In the personal history, five weeks ago, the patient was infected with the contagious hand-mouth-foot disease, which caused fever, sore throat, reduced appetite, and small spots on the mucous membranes in the mouth. [9] The symptoms resolved within a few days without complications.

The overall presentation was accord with EMM. Chest x-ray demonstrated a viral pneumoniae without focal consolidation. Laboratory analysis revealed leukocytosis with significantly elevated C-reactive protein. Serologically were excluded the infections and possible causes of EMM, such as herpes simplex virus (HSV)-1, HSV-2, parvovirus B19, cytomegalievirus (CMV)and Epstein-Barr virus (EBV). The elevated antibodies, in particular, immunoglobulin A (IgA) and IgG against Mycoplasma pneumoniae, led us to the final diagnosis, namely EMM as a secondary disease developing after a primary Mycoplasma pneumoniae infection.

Treatment was started with Antibiotic, namely Clarythromycin and subsequently, due to the substantial mucosal involvement and persisted mucosal ulceration Prednisolone and an adhesive ointment containing glucocorticoids was used. Under these therapeutic measures, lesions together with other symptoms, productive cough, malaise, reduced oral intake showed regression and the patient was discharged at home.

Figure 1: (A) Initially, target-like, round, papulo-urticarial plaques with a livid center, a lighter intermediate zone and a dark red border. (B and C) several pinkish-red, eroded lesions on theupper extremities. (D) Hemorrhagic-crusted lesions, plaques on the labium superius oris und labium inferius oris.