Ulcero‐necrotic monkeypox, a clue for an underlying immunosuppressive disease: Report of two cases

Dear Editor, Monkeypox is a viral zoonotic infection caused by an orthopoxvirus resulting in a rash similar to the one from smallpox, eradicated in the 1970s. Although before 2022 most cases of monkeypox occurred in Central and West Africa, since May 2022 there is an ongoing outbreak associated with persontoperson transmission which has involved tens of nonendemic countries.1 Fortunately, this spread outside close, often skintoskin contact is significantly less than for smallpox, as so is its mortality. There is still not a clear understanding of the virulence and transmissibility of this infection due to inconsistencies between epidemiological investigations.2 A proven treatment for human monkeypox, Tecovirimat— a drug which blocks the final steps in viral maturation and release from the infected cell3— has been put to use for those with severe or complicated infections with satisfactory results.4 We present a 43yearold woman, kidney transplant recipient on triple immunosuppressor therapy, with a history of poorly controlled diabetes, and a 29yearold male patient with no previous medical record, who both presented to the Emergency department with deterioration of their general condition and multiple umbilicated pustules. Although no other epidemiological risk factors were described in the first case, monkeypox infection was clinically suspected and microbiologically confirmed during admission. Initially, the lesions progressed in number and extension to deep ulcers with a central necrotic eschar and pustular periphery, developing multiple cellulitis episodes (Figure 1). Tecovirimat was started 5 days after diagnosis, observing very slow improvement of the lesions with persistence of positivity for monkeypox virus 1 month after diagnosis. In the second case, the patient acknowledged unsafe sexual practices. Suspicion for Monkeypox infection was high and later confirmed during his admission due to abscessificated proctitis, which ended up requiring a discharge colostomy. Due to this atypical presentation, associated immunosuppression was also suspected, and an HIV primoinfection with a 27 CD4 Tlymphocyte count and high viral replication was discovered. He started antiretroviral therapy, as well as Tecovirimat for 14 days given his immunosuppression plus poor clinical course. He had an initial good response with decreasing in size of the lesions and evolution to scabbing. However, he had a relapse after completion of the Tecovirimat regime, with reappearance of new lesions (Figure 2). After topical corticosteroid treatment being ineffective, topical 1% Cidofovir cream was initiated according to literature experience,5 which induced an inflammatory local response following the reduction of the size of the lesions and loss of the pustular component. This improvement, however, may be partially attributed to a component of immune reconstitution due to antiretroviral treatment. We present two cases of generalized, ulceronecrotic Monkeypox skin lesions who were treated with Tecovirimat. These presentations and torpid course were key for the diagnosis of an underlying, not known Received: 9 November 2022 | Accepted: 16 January 2023