Persistent and Severe Mpox Keratitis Despite Systemic and Topical Treatment

Area of Science:

• Ophthalmology
• Infectious Diseases
• Virology

Background:

• Mpox (monkeypox) virus infection can present with ocular manifestations.
• Peripheral ulcerative keratitis (PUK) is a severe inflammatory condition of the cornea.

Observation:

• A case report of an immunocompetent 54-year-old man with mucocutaneous mpox who developed conjunctivitis and subsequently peripheral ulcerative keratitis (PUK).
• Ocular mpox infection persisted for over 6 months, showing epithelial defects, limbitis, endotheliitis, neurotrophic changes, and trabeculitis.
• Despite multiple courses of antiviral treatments (trifluorothymidine, tecovirimat, cidofovir) and an amniotic membrane transplant, corneal inflammation persisted.

Findings:

• Mpox keratitis was confirmed via corneal polymerase chain reaction (PCR) and positive mpox culture.
• Persistent corneal inflammation and viral replication were observed despite antiviral therapy.
• Cycle threshold (Ct) values from PCR were useful for diagnosis and monitoring treatment effectiveness.

Implications:

• Mpox virus can cause prolonged ocular disease, including severe keratitis, in immunocompetent individuals.
• Prior topical corticosteroid treatment may exacerbate the severity and duration of mpox-related keratitis.
• PCR Ct values can serve as a valuable tool for managing mpox keratitis.