Severe Orofacial Manifestations in Monkeypox Infection

A 30-year-old man with recent diagnosis of HIV-infection was seen in the hospital, because of a 1-month history of swollen lips, painful oral mucosa ulcers, cervical lymph nodes and skin lesions. The medical history showed a previous patient contact with 10 subjects, with positivity for Monkeypox virus in 8 subjects. A week later, he began with lesions on the genitals, managed with acyclovir, and subsequent development of manifestations in the mouth and skin, with dissemination to the entire body. He was admitted to our clinic for increased volume in penis and scrotum, and a disseminated dermatosis affecting all body segments, characterized by polymorphic lesions reflecting various stages; the condition presents as infiltrated plaques with a central eschar and two halos at the periphery: one pale and another erythematous, of varying sizes, accompanied by significant edema (Figure 1A). In the mouth there was lip edema, with the presence of multiple superficial round ulcers and vesicles, with a hemorrhagic center and a white-yellowish border, that coalesce forming circinate plaques, with serohematic crusts on the upper vermilion and hematic and meliceric crusts on the lower one, as well as pale mucosa (Figure 1B). Intraorally, painful large shallow ulcers, covered with fibrin and hemorrhagic areas, with rounded and irregular edges, affected both labial mucous membranes, the hard palate and gums, with gingival enlargement and necrosis of the interdental papillae (Figure 1C); the tongue showed partial atrophy of filiform papillae with some isolated punctiform ulcers. A presumptive diagnosis of Monkeypox infection was suggested. Biopsies on lower labial mucosa and plantar skin were performed. Analysis of blood test revealed: hemoglobin 10.8 (13.1 - 18.1) g/dL, iron 22 µg/dL (50 - 212), ferritin 2362 (23 - 336,2) ng/mL, leukocytes 10.8 (3.9 - 10.1)/mm3, aspartate aminotransferase 47.3 (13 - 39) U/L, albumin 2.4 (3.5 - 5.7) g/dL, CD4 count 121 (500-1500) cells/mm3 and HIV-viral load 312,000 (<20-75) copies/mL, starting antiretroviral therapy with bictegravir/emtricitabine/tenofovir alafenamide (biktarvy) and management with antibacterials and antivirals. The histopathological study of lesions was compatible with monkeypox infection and PCR test for the monkeypox virus confirmed the diagnosis (1,2). The patient had increased difficulty in swallowing, first with solids then with liquids; and, given the risk of airway obstruction due to oropharyngeal edema, a tracheostomy was performed. Disease progression was observed, with kidney damage and pulmonary dysfunction, and he died a month later. Mucocutaneous and other clinical features such as fever, chills, headache, muscular pains, backaches, and weariness, are some of the first symptoms of a Monkeypox infection.(2-5) A gradual maculopapular rash with lesion diameters ranging from 0.2-1 cm appears after the prodrome stage; initially on the face and neck, and moving to the legs with involvement of the palms and soles, spreading throughout the body.(2, 5) These last characteristics favored the initial diagnosis of a Monkeypox infection in our patient. Differential diagnosis should include other pox-like viruses, such as varicella, herpes zoster, measles, and arboviruses (Dengue, Zika and chikungunya). (2) This case represents a rare situation where the host rapidly developed progressive worsening of Monkeypox manifestations in HIV-infection.