Case Report: Mpox - Not Just a Rash

Abstract

Mpox (formally monkeypox) is an Orthopoxvirus associated with both zoonotic and person-to-person spread. Human mpox classically presents with rash and systemic symptoms. Although sporadic outbreaks of mpox have occurred worldwide, the 2022 outbreak is the first of pandemic significance. Thousands of geographically dispersed cases were reported beginning in May 2022. The clinical presentations and outcomes of mpox infection have varied greatly based on viral clade. Further guidance is needed for clinicians to diagnose and treat this emerging infection. We present five clinical vignettes of confirmed cases diagnosed in June and July 2022 in northern California to demonstrate the range of mpox disease, including myocarditis, pharyngitis, epididymitis, and proctitis. We note a significant overlap with HIV infection and a high rate of concurrent sexually transmitted infection. Given the heterogenous presentations of mpox disease, clinicians should maintain a high degree of suspicion in patients with oropharyngeal or genital lesions, proctitis, or new rash.

Figure 1.

(A) Painless penile papules with broad umbilication prior to the development of phimosis. (B) Solitary umbilicated papule on foreskin with posthitis.

Figure 2.

(A) Intact perianal region from which detectable Orthopox DNA was isolated prior to the development of cutaneous lesions. (B) Subtle lesions at the deltoid that developed approximately 48 hours after positive Orthopoxvirus DNA testing.

Figure 3.

Images of lesions from confirmed mpox cases. (A) Diffuse pruritic erythematous papules. (B) Isolated, faintly umbilicated papule on knuckle, about 48 hours after onset of lesion. (C) Sparse, umbilicated papules on the back of a patient with severe pharyngitis.