Monkeypox virus infection in an immunocompromised patient

By Bhavana KunkalikarReviewed by Danielle Ellis, B.Sc.Sep 19 2022

In a recent study published in The Lancet, researchers assessed the manifestations of the monkeypox infection in an immunocompromised patient.

Background

The monkeypox virus, a member of the Poxviridae family and the Orthopoxvirus genus, is the causal virus of monkeypox infections. Large respiratory droplets, indirect or direct contact with physiological fluids or lesion material, or contact with biota—including bedding or towels—are some of the primary modes of viral transmission. Within one to three days of fever onset, symptoms such as malaise, headache, lymphadenopathy, myalgia, and cutaneous symptoms have been reported.

Lesions may first appear as macules before developing into papules, pustules, and vesicles before drying up and peeling off. The appearance of skin lesions along with viral prodromal symptoms among immunocompromised patients, in particular, should be evaluated for other diagnoses, such as primary or secondary infection with the varicella zoster virus or other pathogens like Cryptococcus neoformans, Histoplasma capsulatum, or Bartonella henselae.

Case study

A 37-year-old man attended the hospital who reported a rash on his legs, arms, torso, and groin, along with symptoms including generalized malaise, chills, fever, sore throat, and headache that had been present for a week. The patient also experienced discomfort and pain in his rectum during defecation. He had a history of secondary syphilis, which had been treated along with human immunodeficiency virus (HIV), metastatic Kaposi sarcoma, and hypertension. Emtricitabine-tenofovir, darunavir-cobicistat, doravarine, and hydrochlorothiazide were the medications prescribed to the patient.

The patient denied having recently traveled or come into contact with people or animals with similar rashes or ailments. He stated that he had had all of his childhood vaccines and that he had no prior history of varicella-zoster virus infection. The patient claimed to have had no sexual activity for the preceding six months.

Results

The patient's temperature was 37.3°C when he was examined. On the trunk, upper and lower limbs, groin, and peri-anal region, he exhibited a number of dispersed, pink, umbilicated papules, vesicles, and pustules. The laboratory tests showed that hemoglobin levels were 12.7 g/dL, CD4+ T-helper cell count was 262 cells per mcL, HIV-1 ribonucleic acid (RNA) polymerase chain reaction (PCR) was less than 20 copies per mL, and absolute lymphocyte count was 301 per uL. Bartonella henselae, Aspergillus species, hepatitis A, B, and C, cryptococcal antigen, herpes simplex virus types 1 (HSV-1), 2 (HSV-2), and (13)-D-glucan were not detected in the serological samples.

HSV-1, HSV-2, and Treponema pallidum were not detected by immunohistochemical examination of a biopsy sample obtained from one of the truncal papules. Furthermore, spirochetes and fungi were not detected by Warthin-Starry staining or periodic-acid-Schiff staining, respectively. The biopsy sample's histopathological examination revealed focal epidermal necrosis, acute inflammation underneath the superficial dermis, and individually necrotic keratinocytes at the periphery.

The human monkeypox virus was detected in a Dacron swab collected from one of the truncal lesions. The patient was prescribed doxycycline, ceftriaxone, and valacyclovir in light of his history of immunosuppression. The patient was also treated with a two-week regimen of 600 mg of tecovirimat twice daily. He reported no notable side effects and that the skin blemishes healed quickly. The patient indicated he was doing well and noted regions of hyperpigmentation at the regions of the healed lesions during the follow-up appointment one month later.

Conclusion

Overall, the study demonstrated that tecovirimat could be utilized for effective and safe treatment of severe instances of monkeypox infections among immunocompromised patients, pediatric populations, pregnant or nursing women, and those with comorbidities.