Case history
Case history #1
A 32-year-old man has a genital rash that started 8 days ago as painless white pustules on his penis, and subsequently became painful and itchy. He reports recent travel within Europe where he had unprotected insertive anal intercourse with two different casual male partners. The rash started approximately 5 days after these encounters, and subsequently spread to his trunk, face, and hands. The man reports fever, swollen glands, and feeling very unwell starting 3 days after the appearance of the rash. On exam, the lesions on his genitals appear to be crusted over, while the lesions on his face, trunk, and limbs are sparse but in multiple stages of evolution (lesions are in the papular, vesicular, and pustular phases). Routine blood tests are normal. Real-time reverse transcription polymerase chain reaction (RT-PCR) assays for varicella zoster virus, herpes simplex virus, Chlamydia trachomatis, and Neisseria gonorrhoeae are all negative. Syphilis serology is also negative. Mpox is suspected and specimens are collected and sent for laboratory testing.
Case history #2
A 25-year-old woman presents to the emergency department with rigors, chills, and a scanty generalized blistering rash. She reports returning from a remote part of the Democratic Republic of Congo 1 week prior, where she was working as an anthropologist. The fever started 2 days after her return. She reports that two of the children in the compound where she was staying had a similar rash and were unwell when she left. Her medication history includes doxycycline for malaria prophylaxis, which she is still taking. On exam, the vesicles are all at the same stage of development, and are more numerous on her face and limbs than her body. Cervical/axillary lymphadenopathy is present. She has a fever (101.3°F [38.5°C]), is mildly hypotensive (blood pressure of 100/60 mmHg), and has tachycardia (90 bpm). Blood tests reveal a negative malaria film, mild thrombocytopenia, mild lymphopenia, normal blood chemistries, and normal lactate. Mpox is suspected given the characteristic appearance of the rash and the epidemiologic link with Central Africa, and specimens are collected and sent for laboratory testing.
Other presentations
The clinical presentation during the 2022 global clade II mpox outbreak has been atypical. Lesions have been localized to the genital, perineal/perianal, or perioral areas and often do not spread further. There may only be a few lesions, a single lesion, or no visible lesions. Lesions may be at different stages of development, and may appear before prodromal symptoms. Anorectal symptoms have been unique to the outbreak, and proctitis may be the only presenting symptom in some patients.
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