Resolution of Stubborn Monkeypox With Tecovirimat in an HIV Patient

A 40-year-old male with a history of human immunodeficiency virus (HIV) (CD4 absolute count 57 cells/uL) presented to the Emergency Department complaining of large, swollen abscesses on his face, right hand, and feet. He reported the outbreak of the lesions occurred four months ago and coincided with a week-long episode of diarrhea, rectal pain, and perirectal and inguinal lymphadenopathy. Physical exam was significant for a full-thickness fluid collection on the sole of the right foot, a plantar abscess on the left foot, an open, crusted ulcer on the left fifth finger, and several large, crusted lesions on the face. Of note, the patient was seen at a nearby hospital three months prior, underwent a biopsy that showed non-variola orthopoxvirus DNA via real-time polymerase chain reaction (PCR), and was diagnosed with monkeypox at that time. He was advised to pick up tecovirimat treatment from the Department of Health but stated it was unavailable when he arrived and never took it. On this admission, the lesion was again biopsied and detected non-variola orthopoxvirus DNA by real-time PCR. The patient was discharged on 600 mg tecovirimat orally twice daily for 14 days. At the 14-day follow-up, the patient's lesions had completely fallen off and were no longer painful.