Atypical Presentation of Mpox as Acute Tonsillitis: A Case Report from the United Arab Emirates

Mpox typically presents with a prodrome of fever and lymphadenopathy followed by a characteristic vesiculopustular rash. Mpox may present with atypical manifestations, including isolated oropharyngeal, anogenital, and mucosal involvement preceding cutaneous lesions. Recognition of these atypical phenotypes is essential to avoid diagnostic delay and limit secondary transmission, particularly in regions such as the United Arab Emirates and the wider Gulf where published descriptions of atypical presentations remain limited. A previously healthy 28-year-old man in the United Arab Emirates presented with a two-day history of severe sore throat and painful swallowing that prevented oral intake. Examination revealed bilateral erythematous palatine tonsils with cryptic exudate, an edematous uvula, and pharyngeal erythema. There was no stridor or respiratory distress. Inflammatory markers were elevated (WBC count 14.0 × 10⁹/L; CRP 102 mg/L). Computed tomography of the neck demonstrated bulky, heterogeneous palatine tonsils with significant narrowing of the oropharyngeal lumen and reactive cervical lymphadenopathy; the radiologist's impression raised the possibility of evolving abscess. A working diagnosis of acute bacterial tonsillitis was made, and intravenous ceftriaxone and dexamethasone were commenced. On hospital day 2, mild non-specific cutaneous lesions appeared, progressing on day 3 to a characteristic vesiculopustular eruption involving the face, trunk, palms, and genital area. Throat culture, finalised on day 4, yielded normal upper respiratory tract flora with no beta-haemolytic streptococci. Real-time PCR on a skin lesion swab confirmed Mpox virus infection (cycle threshold 12). The patient was isolated, transferred to a designated facility on hospital day 9, and discharged home on 11 January 2026 after a total of 27 days from initial admission. A structured post-discharge telephone follow-up on 12 January 2026 confirmed sustained clinical recovery with full lesion resolution and no recurrent symptoms. Mpox can present initially as severe pharyngotonsillitis with significant oropharyngeal luminal narrowing, mimicking acute bacterial infection and preceding the appearance of skin lesions by several days, even in young, immunocompetent patients without recognised epidemiological risk factors. Clinicians should consider Mpox in patients with severe pharyngotonsillitis, particularly when bacterial cultures are negative or when even subtle cutaneous changes appear during admission, to enable timely isolation and appropriate management.