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Introduction: Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in children, with up to 30% developing extrapulmonary manifestations, including mucocutaneous disease. Mycoplasma-induced rash and mucositis (MIRM) is a distinct clinical entity characterized by prominent mucositis and limited skin involvement, typically affecting the oral, ocular, and urogenital mucosa. While most cases are self-limited, severe presentations requiring intensive care are rare. Description: An 8-year-old previously healthy male presented with fever, cough, and progressive dyspnea, admitted to the pediatric ward for presumed Mycoplasma pneumonia and primary HSV infection. Over the following 48 hours, the patient developed worsening symptoms including bilateral conjunctival injection with hemorrhage, extensive oral and genital ulceration, and a diffuse erythematous maculopapular rash with bullous lesions on extremities. Concern for SJS prompted transfer to the PICU for closer monitoring and management. In the PICU, the patient exhibited signs of respiratory distress requiring non-invasive mechanical ventilation (BiPAP). He required multimodal IV analgesia due to severe mucosal pain, and was started and had a prolong course of total parenteral nutrition given his inability to tolerate oral intake. Infectious and autoimmune workups were initiated. Dermatology consultation and a skin punch biopsy revealed superficial perivascular dermatitis with rare eosinophils, findings consistent with MIRM. The patient was treated with IVIG, in addition to supportive care. Over the next several days, he showed marked improvement in respiratory status and mucocutaneous lesions. He was weaned off respiratory and nutritional support. He was discharged home in stable condition with complete clinical resolution. Discussion: This case highlights a rare and severe presentation of MIRM with respiratory compromise, an occurrence seen in fewer than 5% of pediatric cases. Differentiating MIRM from SJS is essential, as management and prognosis differ. While supportive care remains the mainstay of treatment, immunomodulatory therapies such as IVIG may be beneficial in select cases. Increased recognition of MIRM’s clinical spectrum is critical to avoid misdiagnosis, guide appropriate management, and optimize outcomes.