Monkeypox with exclusive genital lesions.

Abstract

A 30-year-old homosexual man with a history of numerous risky sexual contacts and syphilis treated with benzathine penicillin half a year ago was admitted to our department with multiple small ulcerations in the genital area. Approximately 2 weeks before admission, the patient developed penile pustular umbilicated lesions (Figure 1a) and purulent discharge from the urethra. Gonorrhoea was diagnosed and the patient received a single dose of ceftriaxone 1 g and azithromycin 1.5 g. The purulent discharge from the urethra stopped, but the skin lesions continued to enlarge. Moreover, the black crusts covered the central part of the lesions (Figure 1b). The patient developed fever, which lasted for 4 days. On admission, physical examination revealed painless multiple ulcerative lesions with a central necrotic crust located on the penis (Figure 1c). The inguinal lymph nodes were enlarged. Laboratory tests showed a slight leukocytosis 10.53 × 109/L (normal 4–10 × 109/L) with lymphocytosis 4.1 × 109/L (normal 1.5–3.5 × 109/L), slightly elevated C-reactive protein 5.4 mg/L (normal 0.2–5 mg/L) and negative virological tests for HIV, HBV and HCV. The microbiological test for H. ducreyi infection was also negative. Due to the clinical picture suggesting viral disease, the swab from the skin lesions for monkeypox was taken and turned positive in the polymerase-chain-reaction assay. Only local antiseptics were used in the treatment. Due to the marked clinical improvement within a few days, the patient was discharged home. Monkeypox is a zoonotic infection caused by an orthopoxvirus that has been endemic in central and western Africa since the 1970s, but has recently spread to many countries around the world.1, 2 The typical clinical picture includes prodromal symptoms such as fever, headache and malaise followed by skin lesions ranging from maculopapular lesions to vesicles to pustules. Enlarged lymph nodes are usually observed.2 Epidemiological data show that new cases of monkeypox differ from previous ones in terms of clinical presentation, risk groups and transmission route. New cases mainly affect young men who have sexual contact with other men (MSM) and may coexist with other sexually transmitted diseases.3, 4 The incidence of general symptoms in this group of patients is about 86.3%, with the most common being fever and lymphadenopathy in 61.9% and 57.9% of cases, respectively. However, apart from the typical rash, skin and mucosal lesions often appear in the perianal and genital areas. In addition, atypical symptoms such as rectal pain and penile oedema have also been described.4 Therefore, in the diagnosis of monkeypox, special attention should be paid to high-risk groups, such as MSM, and the fact that skin manifestations may be limited to the genital area only. Moreover, the changing clinical picture depending on the time from the onset of symptoms should be taken into consideration. No funding to declare. JCS has served as an advisor for AbbVie, LEO Pharma, Menlo Therapeutics, Novartis, Pierre Fabre, Sienna Biopharmaceuticals and Trevi; has received speaker honoraria from AbbVie, Eli Lilly, Janssen, LEO Pharma, Novartis, Sanofi-Genzyme, Sun Pharma and Berlin-Chemie Mennarini; has served as an investigator and has received funding from AbbVie, Amgen, Galapagos, Holm, Incyte Corporation, InflaRX, Janssen, Menlo Therapeutics, Merck, Boehringer Ingelheim, Novartis, Pfizer, Regeneron, Trevi and UCB. Other authors reported no conflicts of interests. Data sharing is not applicable to this article as no data sets were generated or analysed during the current study. The patient in this manuscript has given his written informed consent to publication his case details.