Presentations

Abstract

Introduction: Mpox (previously referred to as monkeypox) is a viral zoonotic infection that is caused by monkeypox virus and results in a rash similar to that of smallpox. Monkypox was renamed to follow current best practices of not naming diseases after animals or geographic locations to reduce any stigma that could be associated with the original name. Mpox virus is an orthopoxvirus that is in the same genus as variola (the causative agent of smallpox) and vaccinia viruses (the virus used in the smallpox vaccine) Recently a global health emergency was declared with outbreaks amongst men who have sex with men. As of January 2023, over 84,000 cases have been identified. Mpox can be transmitted through fomites, respiratory secretions and direct contact. It can present with lymphadenopathy, fever, myalgias and headaches with 96% of patients presenting with a diffuse rash. We present a case of Mpox with an unusual and interesting course.

Case Information: A 40-year-old male with HIV not on antiretroviral therapy and secondary syphilis 2 years prior with self-reported treatment presented with diaphoresis, malaise, abdominal and rectal pain for one week. He acknowledged participating in anal-receptive sex. Physical exam revealed non-purulent, non-bleeding rectal warts. His CD4 count was 347 cells/microL and his RPR was reactive with titers of 1:4 which previously were 1:64. Transaminase were elevated with ALT of 295 U/L, AST of 199 U/L and Alkaline Phosphatase of 463 U/L Acute viral hepatitis panel was negative. CT scan reveals findings consistent with proctitis, cystitis and splenomegaly. The patient declined gonococcal swab and was treated empirically with ceftriaxone and doxycycline but rectal pain and diaphoresis persisted. Approximately 4 days after admission, the patient developed discrete, tender pustules on the hands and lower extremities. Dermatology was consulted and PCR from a skin lesion tested positive for Mpox. The patient was appropriately isolated and received supportive treatment. Anti-viral administration was considered but not given as the patient was feeling better. The patient continued to clinically improve with resolution of diaphoresis, abdominal and rectal pain. His LFTs drastically improved and his skin lesions resolved. He was ultimately diagnosed with Mpox induced hepatitis, proctitis and skin lesions.

Discussion/Clinical Findings: Outbreak regions have reported approximately 2% of those with PCR positive Mpox presented with complications of proctitis with 40% of those being people living with HIV. Those who participated in anal-receptive sex practices were found to present more often with proctitis and systemic symptoms before rash, as our patient did. In addition, patients with Mpox can present with hepatitis with ALT and AST elevation which can be used as a poor prognostic indicator. For persons with HIV who have Mpox, anti-monkeypox virus therapy should be considered for those who are immunocompromised and at risk for severe disease (CD4 count <350 cells/microL) For those taking antiretroviral therapy (ART), ART should be continued. For persons with newly diagnosed HIV and those who are not taking ART, ART should be started/restarted as soon as possible. Mpox is a multisystem disorder which can be very tricky to diagnose.

Conclusion: Mpox is a multisystem disorder which can be very tricky to diagnose. It can present with lymphadenopathy, fevers, myalgias. Mpox can present both with and without rash with prodromal phase and clinicians must have high index of suspicion. With the new outbreak of Mpox, it carries a higher mortality rate with infection. Patients with severe disease can be treated with antivirals such as tecovirimat and those at higher risk can benefit from vaccination.