Corresponding Author:
Nikhila Gandrakota MBBS, MPH
Department of Family Medicine
Emory University, Atlanta, GA, US
nikhila.gandrakota@emory.edu
Keywords: Monkey pox, HIV, AIDS, cellulitis, syphilis,
Hepatitis C, COVID
AbstractMonkeypox infections in the US and across the world have been rising
in the past few months. Most of these infections have been found to be
transmitted among men who have sex with men (MSM). Our case report
discusses the rare presentation of a patient with monkeypox along with
multiple comorbidities, including AIDS, late latent syphilis, acute
hepatitis C, and asymptomatic and scrotal and penile cellulitis
secondary to MRSA. Further, our case report raises discussion on the
need for further research to identify the effect of monkeypox vaccine
on symptomatic patients who are immunocompromised.
Introduction:Monkeypox belongs to the group of orthopox viruses, endemic to Western
and Central Africa. The zoonotic virus was first identified in monkeys
in 1959, however, the first human case was not reported until 1970
[1]. Two cases reported in the US in 2021 were linked to
individuals returning after an international travel to Nigeria
[1]. Following these reports, the number of Monkeypox infections
began to increase, reaching approximately 84,330 infections reported
globally by January 2023 in 110 countries [5]. The specific
reservoir host of the virus has not been identified; however, it is
suspected to be an African rodent. The infection has been shown to
spread through the exchange of skin-to-skin contact, bodily fluids
(semen, vaginal fluids), and respiratory droplets. The majority of
infections have been found to be transmitted among men who have sex
with men (MSM). In over 50% of cases, the first presenting symptom
has been a rash (often vesicular, with ulcers or crusts) predominantly
over the face, limbs, and occasionally trunk [1]. Additional
reported symptoms include fevers, chills, headache, and
lymphadenopathy [2]. Diagnosis is most accurately obtained by PCR
(polymerase chain reaction) of the swabbed skin lesions as these areas
contain the highest concentration of virus; samples can also be
obtained from oropharyngeal and nasopharyngeal swabs as patients often
present with oropharyngeal or perioral lesions.
Our case report describes the concurrent infection of Monkeypox in the
setting of severe immunodeficiency (AIDS), late latent syphilis, and
acute hepatitis C, with scrotal and penile cellulitis secondary to MRSA.
Case Description:A 37-year-old African American male with a history of untreated HIV,
and syphilis (previously treated in 2014), presented to an outside
hospital Emergency Department in Metro Atlanta for ulceration and
irritation of lesions on the penis and scrotum. A swab of the lesions
was collected, and a DNA PCR was collected, which later confirmed the
diagnosis of Monkeypox. During that encounter, he was administered a
second dose of the monkeypox vaccine and discharged home with
Augmentin and Mupirocin ointment.
Four days later, he presented again to the same Emergency Department
with a diffuse rash on the nose, back, face, chest, and arms and
induration with multiple ulcerations on the penis. He was admitted to
the hospital for further care. An RPR (rapid plasma reagent) returned
with 1:128 titer, and FTA-ABS (Fluorescent treponemal antibody
absorption test) was positive. A bacterial culture of penile
ulcerations was positive for MSSA (methicillin-sensitive
Staphylococcus aureus) and MRSA (methicillin-resistant staphylococcus
aureus). He was diagnosed with cellulitis of penis secondary to
monkeypox and syphilis and an immunocompromised state. He was
initially treated with Vancomycin and Unasyn, and a one-time dose of
Dalvance (Dalbavancin). Vancomycin was later switched to Daptomycin
due to an AKI (Acute Kidney Injury). He was also treated with a dose
of 2.4 million units of penicillin for syphilis. His CD4 count was
noted to be 129, and thus he received Bactrim for PCP (pneumocystis
pneumonia) prophylaxis. His Cryptococcal Antigen and Toxoplasma IgG
were negative (<7.20), and Quantiferon TB was indeterminate.
Other findings included positive acute hepatitis A and hepatitis
C infections with Hepatitis A IgM and Hepatitis C IgM antibodies
positive, and a Hepatitis C RNA PCR viral load of 10,000 IU/mL. He was
recommended to start treatment six months after discharge. He was
scheduled for a follow-up with infectious disease and was prescribed
anti-retroviral therapy with Biktarvy
(bictegravir/emtricitabine/tenofovir alafenamide) Bactrim. He also
coincidentally tested positive for COVID-19 on this admission however
remained asymptomatic. He then left against medical advice from this
hospital for unclear reasons.
He presented to our Emergency Department three weeks later with a
complaint of fatigue. He had not been compliant with Bactrim or
Biktarvy and stated that he had just been made aware of the diagnoses
of both HIV and syphilis three weeks prior. He expressed discomfort
from whole-body and oral lesions, however, denied any fevers, chills,
urinary complaints, or pain.
At the time of presentation, he was found to be tachycardic with initial
heart rate of 120 beats per minute, afebrile, and other vital signs were
stable. An electrocardiogram revealed sinus tachycardia with no evidence
of ischemia. Labs were significant for hyponatremia with sodium of 127,
and white blood cell count of 11,000 per microliter. He received 1 liter
bolus of IV lactated ringer’s and was placed on sepsis protocol. He was
admitted for further evaluation and management.
After discussion with infectious disease specialists, it was considered
beneficial to initiate anti-viral treatment for Monkeypox lesions given
prolonged course of symptoms in the setting of immunodeficiency. He was
started on Tecovirimat (Tpoxx) course planned for a total of 28 doses.
This was initially administered intravenously due to difficulty
tolerating oral intake in setting of oral lesions. This was transitioned
to oral once he was evaluated by speech and language pathologists and
was deemed able to tolerate oral intake. His CD4 count returned at 63;
thus, Bactrim was initiated for PCP prophylaxis. HIV viral load returned
with greater than 230,000 copies/microliter. ART was initiated with
Biktarvy. RPR resulted reactive with titer of 1:64. He was treated for
late latent syphilis and given two doses of bicillin 2.4 million units
each one week apart for a total of three total doses (first dose was
already given at outside hospital). Blood cultures showed no growth
throughout the admission period of 13 days.
The patient also had scrotal and penile cellulitis and was found to have
significant scrotal edema with superficial overlying gangrenous changes
on the scrotum and penis on examination. Urine culture returned with
50,000-99,000 CFU/mL Pseudomonas aeruginosa and 10,000-49,000 CFU/mL
Klebsiella pneumoniae. A scrotal ultrasound revealed scrotal edema with
concern for abscess, and thus, an MRI of the pelvis was obtained, which
revealed superficial cellulitis without an abscess. Urology was
consulted, and he was started on empiric antibiotic therapy with
vancomycin, ceftriaxone, and metronidazole. Throughout his admission, he
had intermittent episodes of urinary retention. However, he did not
require catheterization and was able to urinate without issues with
adequate daily urine output. He was discharged with a recommendation to
follow up with a Urology out-patient for surgical debridement after one
month of ART due to the high risk for superimposed infections secondary
to an immunocompromised state. He was discharged home with Levaquin and
Doxycycline for a 10-day course. He was also provided a one-week supply
of ART and advised to follow up with Infectious Disease/HIV clinic for
further care.
DiscussionIndividuals with HIV/AIDS are at a higher risk for superimposed
infections due to immunocompromised status [3]. Societal stigma
also creates healthcare barriers and increases community transmission,
resulting in adverse outcomes and increased mortality in these groups.
Clinically, there was difficulty discerning whether this patient’s
whole-body and facial lesions were from monkeypox alone or gummas,
which are a manifestation of tertiary syphilis, due to similarities in
gross appearance (Figures 1, 2 and 3). Per the state health
department’s records, it was noted that the patient had received the
diagnosis of HIV and syphilis in July 2014, which was over eight years
prior to the current presentation. The patient reported he was unaware
of these diagnoses and did not seek care with initial symptoms due to
general mistrust of the healthcare system. He did not receive adequate
care until presentation with advanced-stage of Monkeypox infection and
disseminated syphilis in the setting of AIDS. In order to prevent such
outcomes in such vulnerable populations, an argument can be made to
encourage screening for co-infections to ensure appropriate and
thorough treatment and management [2].
It has been postulated that societal stigma and internalized stigma
among people living with HIV (PLHIV) creates a significant barrier to
care [3]. According to AIDSVu, 60% of black men in metro Atlanta
are diagnosed with HIV by age 30, and 22% have already progressed to
AIDS within 3 months of diagnosis [4]. Hence, frequent follow ups
should be encouraged in individuals with HIV to ensure adherence to ART,
optimize recommended vaccinations and preventive care to reduce
progression to AIDS, and mitigate community transmission. Efforts should
also be made to screen PLHIV (Persons Living with HIV) for
illness-related depression and other mental health issues that may
further impede their willingness to seek care and access resources.
Healthcare workers should encourage PLHIV to develop adequate social
support systems to reduce the negative impact of stigma [3].
Overall, public health campaigns should encourage general preventive
measures such as hand hygiene, isolation for exposed and infected
persons with infection, and use of post-exposure vaccines in vulnerable
communities [1].
Also, this patient received the second dose of the monkeypox vaccine
after the development of a few lesions. However, receiving the live
vaccine is not recommended once a monkeypox patient is symptomatic
[6]. It is unclear whether the live vaccine may have exacerbated
this patient’s condition, and more studies are necessary to evaluate the
impact of the live vaccine on immunocompromised individuals with
symptomatic monkeypox.
Conclusion
Further studies are needed to evaluate appropriate algorithms for
routine screening for monkeypox and other sexually-transmitted
infections in high-risk and vulnerable populations. Additionally,
healthcare reforms should be implemented in both clinical settings and
elsewhere to destigmatize the experience of people living with HIV and
encourage initiatives to increase awareness and incorporate more
effective preventive measures.
Figure 1: Day 1: Lesions on Face
Figure 2: Day 1: Lesions on face
Figure 3: Day 1: Lesions in the oral region
Figure 4: Day 1: Lesions on the tongue
Figure 5: Day 1: Lesions on the buccal mucosa
Figure 6: Day 1: Dry gangrenous penile lesion depicting cellulitis
Figure 7: Day 10: Lesions with crusting on face
Funding: None
Conflict of Interest: The authors declare no conflicts of
interest
Patient consent: A written consent was obtained from the
patient for publication