Monkeypox virus case with maculopapular exanthem and proctitis during the Spanish outbreak in 2022

Abstract

Dear Editor, A 30-year-old male patient visited the Emergency Room (ER) on the 16th May 2022 complaining of a new-onset skin rash associated with systemic symptoms. He had not travelled abroad during the previous months. He was diagnosed with HIV infection 9 years prior and maintained a good immune-virologic control under antiretroviral therapy. He also presented past medical history of syphilis, hepatitis B and had been treated for hepatitis C virus. He recognized himself as MSM with high-risk sexual practices1 such as multiple sexual partners, use of recreational drugs and unprotected sexual intercourse 2 weeks prior his admission to the ER. The patient first presented with symptoms of proctitis (rectal bleeding, mucopurulent discharge and tenesmus). Four days later, he experienced a sudden onset of systemic symptoms with fever up to 39.3°C, headache, lymphadenopathy, generalized arthralgia and myalgia. The skin rash began 2 days later, on both arms and dorsum of hands and then spread to the trunk, legs, face and, lastly, genitalia, sparing palms and soles. Physical examination revealed a maculopapular pinkish exanthem associated with numerous flat-topped umbilicated pustules (Fig. 1a–c) with a necrotic centre and surrounded by an erythemato-edematous plaque (Fig. 2). In the genitalia, one single pustule in the penis body (Fig. 1d) and two isolated perianal ulcers were observed. Multiple enlarged painful lymph nodes were present in both inguinal and latero-cervical regions. A pustule exudate was collected and analysed using real-time polymerase chain reaction (RT-PCR) in the Spanish National Center for Microbiology, which resulted positive for monkeypox virus. Blood analysis showed a RPR titre of 1/4, which was stable compared with previous analytical determinations. Rectal, urethral and pharyngeal samples were tested for Chlamydia trachomatis and Neisseria gonorrhoeae, with negative results. Until a few years ago, most of the infections caused by monkeypox (MPX) virus had been detected in central and western Africa,2 mainly related to direct contact with animals.3 Moreover, sporadic cases have recently been described in other countries such as the USA4 or the United Kingdom.5 The disease is characterized by an onset of prodromal symptoms followed by a vesicular-pustular rash that begins on the head and spreads to the rest of the body.2, 6 On 14th May 2022, an alert was given for the appearance of MPX cases in several patients in Great Britain7 and Portugal.8 Two days later, cases began to be diagnosed in Madrid, Spain.8 This outbreak is being characterized by the appearance of lesions more limited to the genital area, with little or non-systemic symptoms and in general with a favourable outcome.9, 10 Most cases reported in our environment during this outbreak are associated with sexual practices,8 probably related to the prolonged proximity that intimate relationships entail. However, our case showed several distinctive features. First, general symptoms were preceded by a severe proctitis, which seems to be caused directly by monkeypox virus. In addition, typical lesions (umbilicated pustules with an ulcero-necrotic centre) often described alone in other publications were accompanied by a maculopapular rash similar to syphilitic roseola. Lastly, in contrast to what was already reported,10 the pustules in our patient began in arms and then extended to the rest of the body surface, affecting mostly to the trunk and proximal limbs. Herein, we present one of the first cases of autochthonous MPX disease detected in Madrid (Spain) with not known epidemiological contact with reservoir animals or travels to an endemic area. The rash with the appearance of vesicles and pustules is the most common manifestation of this disease along with fever and lymphadenopathy.9 However, we suggest that a maculopapular exanthem and proctitis could be considered as additional symptoms associated with MPX disease in some patients. The patient in this manuscript has given written informed consent to the publication of his case details. No funding was obtained for this study. None of the authors have any disclosure of conflict of interest for this work. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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