Monkeypox-associated proctitis and rectal wall perforation

Monkeypox is a viral zoonotic infection which has rapidly increased in incidence and spread globally since May 2022. There have been reports of rectal complications of monkeypox but so far these are not well not understood. Here, we describe a case of rectal pain in HIV-positive man with confirmed monkeypox. MRI on day 5 of hospital admission revealed proctitis with localised perforation. The patient was treated with tecovirimat, antibiotics, analgesia and laxatives and improved without requiring surgical intervention. All patients presenting with new rectal symptoms and deemed high-risk for monkeypox should be isolated and screened for the disease, and appropriate personal protective equipment should be worn by healthcare professionals caring for them. Clinicians should have a low threshold for cross-sectional imaging in patients with confirmed or suspected monkeypox who experience persistent and severe rectal symptoms or who become systemically unwell to investigate for complications such as perforation and abscess formation. The vast majority of monkeypox cases do not require antibiotics and their use should be reserved for patients who show signs of secondary bacterial infection or sepsis.