Monkeypox virus (MPXV) is a zoonotic disease, with endemic circulation predominantly in west and central Africa.1 However, recently MPXV is spreading rapidly. A total of 1285 laboratory-confirmed MPXV cases have been reported in 23 countries by June 20222 being Spain one of the most affected countries. MPXV is not considered a sexually transmitted infection (STI) but the infection occurs through direct contact with the lesions and through body fluids and therefore it may be transmitted during a sexual intercourse.3 Recently, it has been reported a particularly high incidence among men who have sex with men (MSM).2,4,5
We report the first case of a male HIV-negative patient with HIV Pre-Exposition Prophylaxis (PrEP), and a simultaneous coinfection of Monkeypox Virus, Covid19 and Syphilis.
A 56year old man attended emergency because of a painless genital ulcer that appeared 2 days before with no other accompanying symptom. Patient was a MSM with a medical history of depression, type 2 diabetes mellitus and a 7-days hospitalization 6 months before for a COVID-19-related pneumonia. He never reported to be positive for a STI and presented negative serology tests for HIV and LUES 6 months earlier. His ongoing medication included PrEp.
A Polymerase-Chain Reaction test (PCR) for type-1 and -type-2 Herpes Simplex Virus (HSV1-2) on an ulcer swab was performed directly along with a blood test and serology for LUES and other STI (HIV, HBV, HCV). The following day, patient came back due to pain and inflammation of the penis. Physical examination revealed a genital ulcer with indurate edges and a fibrin base, foreskin edema, glans erythema (Fig. 1), painful bilateral inguinal lymph nodes swelling and two punctate erythematous lesions on the extremities. He had 37.7°C temperature while laboratory analysis showed leucocitosis (15000 WBC/mL) and c-reactive protein 13.7mg/L (n.v. ≤5.0). The PCR for HSV1-2 was negative while the serologies for LUES were still pending. The clinical hypothesis for the penile ulcer was an infected syphilitic chancre so patient was admitted to the hospital. As per protocol, a SARS-CoV-2 PCR test was performed prior the admission and test resulted positive.
The results of the STI serology and bacteriological culture of the ulcer performed were: RPR 1/1 (but performed only 2 days after ulcer’s appearance), total antibodies for Treponema Pallidum, MEIA and TPHA positive while serology for HIV, HBV, HCV negative; the bacteriological culture of the ulcer was positive for Staphylococcus aureus. We prescribed a single dose of 2.4 million units of Benzathine penicillin and amoxicillin-clavulanic acid 875/125mg TID iv. At physical examination, we evidenced the appearance of new blistering, pustular and ulcerated lesions on the extremities (Fig. 2), buttocks, chest (Fig. 3) and scalp. Considering the recent outbreaks of monkeypox, we decided to perform a PCR of the scraping of the lesions for MPXV. We took three different samples, two from skin lesions and one from the initial genital lesion, being the first two positive for MPXV.
The patient had a sexual history of MSM without a fixed partner and reported 2 sexual contacts in the last 6 weeks; one of his partners was anonymous sex; he performed active anal sex and oral sex without using a condom. He did not travel to endemic areas recently.
Patient was discharged the 4th day after admission: he was feeling well, the edema of the penis disappeared and the genital ulcer presented a better aspect. The diagnosis was: (1) primary LUES (infected chancre); (2) COVID-19; (3) Monkeypox. Recommendations were to stay home and avoid contact with other people until the skin lesion are gone, contact sexual partners and keep lesions covered.
A week after the discharge, he reported feeling well with no fever: penis’ edema, the genital ulcer and inguinal lymph nodes disappeared and most of the skin lesions were in crusty phase. He contacted one of his sexual partners who was already diagnosed with Monkeypox in another center. We instructed the couple also to have some serologies for syphilis, which resulted positive.
This is the first case report of Shyphilis, Covid-19 and Monkeypox coinfection in a HIV-negative MSM using PrEP. The diagnosis was not easy since the infected ulcer in the penis (chancre) was misleading and because we never seen a monkeypox case before. It is important to have a high level of suspicion to be able to diagnose monkeypox and it is important that in the emergency room a PCR for Monkeypox should be available.
It is very likely that this patient got both Syphilis and Monkeypox from the same sexual partner. In facts, men using PrEP, while not using a condom are not getting infected with HIV, but are at high risk of getting infected of other STI. Being Monekypox sexually transmittable, it is likely that in the future more patients using PrEP are going to get infected with MPXV.
