A 40-year-old Caucasian male living in Florida with past medical history of well-controlled HIV disease [HIV RNA < 20 copies/ml; CD4 count (29%) 742 cells/microl] presented with a new painful, itchy, vesiculopustular rash surrounding the anus and perianal region [Figure 1(a)]. Patient is adherent to oral once-daily single-pill (bictegravir, emtricitabine, and tenofovir alafenamide) antiretroviral therapy (ART) and takes no other medications. He denied any surgical history or known drug allergies. Patient denied any recreational substance use and consumes occasional alcohol during social events. He reported on the day he received the modified vaccinia Ankara vaccine (JYNNEOS) that he had receptive anal intercourse with a new male partner. He had not had any recent domestic or international travel. Within 2 days of that sexual encounter, he noticed subjective fever, myalgia, malaise, and itchiness in the anus. He originally presented to an urgent care facility due to concerns for rectal chlamydial or gonococcal infection. Rash was not seen then, and he was given one intramuscular injection of ceftriaxone and oral doxycycline. The vesiculopustular rash appeared 5 days after the new sexual encounter and is he now being seen in infectious diseases clinic. Due to the current human monkeypox outbreak in Florida, vesiculopustular fluid was sent to Florida Department of Health laboratory for monkeypox virus polymerase chain reaction (PCR) testing. Given his clinical presentation, patient was empirically started on tecovirimat (TPOXX ) 600 mg every 12 h within 48 h after receiving the medication from the US CDC. Rectal swabs for Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acid amplification and syphilis serological testing were negative. Monkeypox virus PCR testing was positively confirmed from vesiculopustular fluid several days later.
After starting oral tecovirimat and over the next 2-3 days, new singular, painful, vesiculopustular lesions had arisen on the posterior left upper extremity and right anterior wrist, right anterior thigh, bilateral hairline, and one lesion on the exterior upper lip. No new perianal lesions appeared and mild fever, myalgias, and malaise began to improve. However, new significant anorectal pain developed with accompanying constipation due to fear of defecation. He was started on oral stool softeners to help with constipation and oral gabapentin, and topical lidocaine to reduce the neuropathic pain. On day 7 of tecovirimat therapy, systemic symptoms had abated, anorectal pain improved, and no new vesiculopustular lesions noted. Resolving features of the existing vesiculopustular rash were seen with crusting and scaling of the lesions [Figure 1(b)]. Anorectal pain had completely subsided at the end of the 14-day course of tecovirimat. Clinical exam conducted 21 days after initial symptoms and yielded a complete resolution of the vesiculopustular lesions. New skin formed in the areas of the previous rash, with most lesions exhibiting pigmented scarring as seen on the wrist (Figure 2) and perianal lesions [Figure 1(c)].