Patient With Genital Lymphedema, Pain, and Rash

Abstract

A 47-year-old man presented to the emergency department (ED) with 3 days of worsening scrotal pain, genital edema, erythema and yellow penile discharge, after completing 2 weeks of doxycycline. He was in an open marriage with a male partner and denied new sexual partners. In the ED he was afebrile and normotensive without tachycardia. His physical exam revealed tender genital lymphedema without crepitus or fluctuance (Figure 1A, 1B). White blood cell count (WBC) was 8.8 × 109/L, Lactate 1.9 mmol/L, and Creatinine 1.22 mg/dL. CT scan revealed no subcutaneous air nor fluid collection. Physical exam evolved with the development of an umbilicated rash with pustules on hospital day #5 (Figure 1C). Tests for HIV, Hepatitis C, HSV-1, HSV-2, Neisseria gonorrhea and Chlamydia trachomatis were negative. His RPR and treponemal antibody were both positive. A)FilariasisB)Monkeypox + SyphilisC)Lymphogranuloma VenereumD)Molluscum Contagiosum + Secondary Syphilis What is the most likely diagnosis? B) Monkeypox + Syphilis In the 2022 United States Monkeypox (MPX) outbreak, infected individuals most often present with a prodrome of fever, lethargy, myalgia, and headache and with subsequent onset of a cutaneous lesions in 95% of cases, most frequently in the anogenital region (73%).1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Transmission occurs through direct and prolonged contact with skin lesions, fomites, and also large respiratory droplets.1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Concomitant sexually transmitted infections (STI) have been seen in up to 29% of cases.1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Furthermore, secondary bacterial infections involving MPX lesions have also been reported.2Ortiz-Martinez Y Rodriguez-Morales Alfonso J Franco-Paredes C Chastain DB Gharamti AA Vargas Barahona L Henao-Martinez AF Monkeypox - a description of the clinical progression of skin lesions: a case report from Colorado, USA.Ther Adv Infect Dis. 2022; 920499361221117726Google Scholar Primary infectious genital lymphedema is most commonly caused by Wuchereria bancrofti, causing Lymphatic Filariasis, which is rare in the U.S.3Pastor C Granick MS. Scrotal lymphedema.Eplasty. 2011; 11 (ic15)https://www.ncbi.nlm.nih.gov/pubmed/22184510Google Scholar Genital lymphedema may also be idiopathic or secondary to prior episodes of Streptococcus cellulitis.4Bjornsdottir S Gottfredsson M Thorisdottir AS et al.Risk Factors for Acute Cellulitis of the Lower Limb: A Prospective Case-Control Study.Clin Infect Dis. 2005; 41: 1416-1422https://doi.org/10.1086/497127Crossref PubMed Scopus (143) Google Scholar Additional considerations include secondary syphilis and Lymphogranuloma Venereum (LV), caused by Chlamydia trachomatis. Secondary syphilis presents with lymphadenopathy and systemic systems, but the presence of extensive perianal pain and proctitis is unusual and more suggestive of MPX.6Basgoz N Brown CM Smole SC et al.Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash.N Engl J Med. 2022; 387: 547-556https://doi.org/10.1056/NEJMcpc2201244Crossref PubMed Scopus (26) Google Scholar The patient described was diagnosed with syphilis by positive RPR and treponemal antibody tests, but this diagnosis alone did not explain his extensive pain. LV is usually characterized by proctitis, proctocolitis, and palpable inguinal and femoral lymph nodes.6Basgoz N Brown CM Smole SC et al.Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash.N Engl J Med. 2022; 387: 547-556https://doi.org/10.1056/NEJMcpc2201244Crossref PubMed Scopus (26) Google Scholar LV usually presents with a primary asymptomatic genital or anal lesion, but disseminated and persistent skin lesions have not been described and are more consistent with MPX. Patients presenting with acute scrotal pain and/or edema even without pathognomonic lesions, should prompt STI evaluation and early MPX precautions.7Gomez-Garberi M Sarrio-Sanz P Martinez-Cayuelas L et al.Genitourinary Lesions Due to Monkeypox.Eur Urol. 2022; 9 (Published online September)https://doi.org/10.1016/j.eururo.2022.08.034Abstract Full Text Full Text PDF Scopus (5) Google Scholar In the described case, the diagnosis was confirmed with DNA PCR testing of a swabbed genital lesion for Orthopoxvirus and Monkeypox Virus (West African Clade). On hospital day #6, the patient was started on Tecovirimat 600mg prescribed twice daily for two weeks. On hospital day #10, the scrotal lesions healed without areas of apparent necrosis, and scrotal edema subsided to baseline. 5Vives F García-Perdomo HA Ocampo-Flórez GM. Giant lymphedema of the penis and scrotum: a case report.Autops Case Rep. 2016; 6: 57-61https://doi.org/10.4322/acr.2016.026Crossref PubMed Google Scholar.