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A Case of Monkeypox Infection in an
Unvaccinated HIV-Positive Male in Rural Alabama
  Kristine Wong, Malvika Chaudhary, Raul Magadia
November 11, 2022
Non-endemic cases of monkeypox infection have been increasingly reported worldwide since early May 2022. Here we report a case of self-limited monkeypox disease in an unvaccinated male who was an HIV patient but did not require treatment with tecovirimat. This is the first reported case of monkeypox in Calhoun County, Alabama.
Monkeypox is a viral zoonosis caused by the monkeypox virus, an enveloped double-stranded DNA virus of the Orthopoxvirus genus in the family Poxviridae [1]. Sporadic endemic outbreaks of monkeypox have been reported in Africa; however, more than 3000 cases have been reported in over 50 countries since early May 2022, prompting greater scrutiny of this virus by the World Health Organization (WHO) as a potential public health concern [2]. Human-to-human transmission of monkeypox results from prolonged close contact with skin lesions, respiratory secretions, or contaminated fomites of an infected individual [3]. Although the current outbreak disproportionately affects gay and bisexual men, evidence of sexual transmission via seminal or vaginal fluids has not yet been demonstrated [2]. Patients with the disease may exhibit systemic symptoms of fever, intense headache, lymphadenopathy, back pain, myalgia, and severe fatigue during the prodrome period for one to five days [3, 1]. Within one to three days of fever onset, a painful rash develops that evolves sequentially from macules to papules, vesicles, pustules, and finally dried crusts that shed from the skin [3, 1]. Its clinical presentation is similar to but notably less severe than that of the smallpox virus, another orthopoxvirus of renown due to its successful eradication worldwide in 1977, thanks in large part to coordinated global vaccination efforts [4]. On August 4, 2022, the United States Department of Health and Human Services declared the monkeypox outbreak a public health emergency. This report describes the first reported case of monkeypox infection in Calhoun County, Alabama, and its clinical course.
Case Presentation
A 52-year-old African American male presented to the emergency department with a one-week history of odynophagia to solids accompanied by pharyngeal and perianal pain without any other systemic symptoms. His past medical history was significant for prediabetes, neuropathy, hepatitis C, and HIV on treatment, but he was non-compliant with an undetectable viral load and a CD4 count of 303 cells/mm3. The patient’s medications included bictegravir (50 mg), emtricitabine (200 mg), and tenofovir alafenamide (25 mg) tablets daily, which he had stopped taking one month before admission. Further questioning revealed that the reason for the cessation of his medication was due to increased stress from moving recently and indifference to his condition. He had no significant family history. Social history was significant for a 20-pack smoking history per year and current tobacco and marijuana use. The patient received one Moderna COVID-19 vaccine and was up-to-date with influenza, pneumococcal, and tetanus vaccinations; however, he did not receive the smallpox vaccine. Three weeks before admission, with a one-month male partner, sexual history was significant for both insertive and receptive oral intercourse. The patient then had another sexual encounter with another male partner after one week, in which the two engaged in both insertive and receptive oral and anal intercourse. Both partners had been exposed to monkeypox by another male partner a few weeks before their encounters with the patient. The patient then developed painful perianal and pharyngeal vesicles one week after intercourse.
Physical examination revealed tonsillar hypertrophy with exudate (Figures 1, 2) and four 2-5 mm ulcerated lesions with overlying eschar on the right buttocks with surrounding erythema and tenderness to palpation (Figures 3, 4).
Computed tomography of the neck with contrast showed evidence of tonsillitis but no lymphadenopathy. Due to a high suspicion of monkeypox, the patient was placed under contact and airborne isolation precautions. Lab findings were significant for an elevated plasma reactive antibody titer of 1:16. Testing for Chlamydia trachomatis and Neisseria gonorrhoeae was negative. Monkeypox infection was confirmed with two positive polymerase chain reaction (PCR) tests to detect the DNA of orthopoxviruses, sampled from two separate lesions.
For syphilis, the patient was given penicillin G intramuscularly three times per week and was restarted on Biktarvy. A psychiatric evaluation was conducted to assess for depression and suicidal intent due to his history of sudden cessation of HIV medication. Throughout his hospital stay, the patient developed one new lesion above the right clavicle, one new lesion on the tip of his nose (Figures 5 and 6), and one macular lesion on the head of the penis. He also experienced the associated symptoms of fever or chills, asthenia, and diaphoresis, followed by pruritus at the tail end of the disease course. The patient is without signs of severe disease and has shown improvement with supportive care alone, without pharmacological treatment with tecovirimat.

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