The patient, aged 36, presented at our HIV outpatient clinic on June 11th, complaining of a cutaneous erythematous-papular rash with both single and clustered elements, not itchy, firstly appeared in the anal region nearly 10 days before and subsequently spread to his torso, upper and lower limbs and ultimately involving his face and palms. Several lesions showed local signs of infection and anal lesions had purulent secretion. During the last few days, the patient had complained fever and a bilateral, painful inguinal lymphoadenopathy was also observed. The patient reported that he had participated to a musical event in a city in Northern Italy a couple of days before the appearance of skin lesions and, on that occasion, he had had an unprotected sexual intercourse. Due to the suspect of MPX, the patient was hospitalized and diverse samples (cutaneous and nasopharyngeal swabs, serum and plasma) were collected and sent to the regional reference laboratory for the detection of Monkeypox viral DNA by real-time polymerase chain reaction (PCR).
Regarding his HIV infection, he was first diagnosed with acquired immunodeficiency syndrome (AIDS) in 2019 and his defining illnesses were disseminated non-tubercular mycobacteriosis and wasting syndrome. The patient received antiretroviral treatment (Darunavir/Cobicistat/Emtricitabine/Tenofovir alafenamide) since then, with undetectable viral load but without fully restoring his immune status: in fact, on admission, his CD4 cell count was of 122/mmc (8.7%). Lastly, the patient had a recent history (April 2022) of secondary syphilis, whose treatment had already been completed at the time of hospitalization.
Laboratory findings on admission were overall within normal range, except for a slight increase of white blood cells (12,22 x 103/mmc, neutrophiles 78%) and an elevated PCR (110 mg/L). Urethral and perianal swabs were also collected to perform culture and PCR, allowing to rule out concurrent sexually transmitted infections, including gonococcal disease and urogenital mycoplasmas.
On the same day of hospitalization, diagnosis of MPX was confirmed by PCR positivity on both skin swabs and plasma. Given the dissemination of skin lesions, the local and laboratory signs of bacterial superinfection, and the immune compromised status of the patient, according to the current WHO and CDC recommendations [4; 5], we decided to administer antiviral treatment with a first single dose of Cidofovir 5 mg/kg (with probenecid); furthermore, since the man was non-compliant towards a prolonged hospitalization, a single administration of Dalbavancin 1500 mg was given for the management of superinfection. Both treatments were very well tolerated by the patient, who was discharged within the next 48 hours showing a remarkable improvement of the skin lesions (Fig. 1) and prompt defervescence. Isolation regimen was recommended, according to the current national and international indications.
He was readmitted after one week in order to receive the second administration of Cidofovir. Upon admission, the skin lesions were overall improved, with an asynchronous evolution; the patients had been constantly afebrile and PCR dropped down to 42 mg/L. On that occasion, plasma was tested again for MPX PCR, which was still detectable. The patient was discharged after 48 hours without complications, and isolation measures were still in place. During the first follow-up visit after one week, MPX PCR was tested on plasma, resulting negative; after 21 days since diagnosis, he was declared healed and isolation was withdrawn.