A 24-year-old Taiwanese man, an MSM with HIV infection, presented on June 22, 2022, to the telemedicine clinic in Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, with scattered vesicular and pustular skin lesions over his face, limbs, trunk, genital, perianal areas; tender, swollen, inguinal lymph nodes bilaterally; fever, sore throat, and myalgia for 2 days (Fig. 1 A-K). He returned to Taiwan from Germany on June 16, 2022, where he had studied for 6 months. He was quarantined due to COVID-19 policies upon arrival. He received 3 doses of COVID-19 vaccination (AstraZeneca, AstraZeneca and BioNTech), with the last dose in Dec, 2021. He was diagnosed to have HIV infection in 2016, and maintained good viral suppression with antiretroviral drugs, with a CD4 count of 517/mm3. His last sexual encounter was in early June, 2022. A travel history to a nonendemic country with monkeypox outbreak, and compatible clinical manifestations alerted the physician to monkeypox, who immediately notified the Taiwan C.D.C. The patient was referred to the emergency department, where a throat swab, vesicular fluid and serum sample were collected and sent to the reference laboratory of Taiwan C.D.C. for molecular detection of MPXV.
Viral DNA extraction with QIAamp MinElute virus spin (Qiagen, Hilden, Germany), and conventional polymerase chain reaction (PCR) was performed to detect Orthopox virus and MPXV based on previous publications.   Both throat swab and vesicular fluid samples from the patient were positive by PCR using Orthopox virus and MPXV specific primers, and sequences of the PCR products were obtained. MPVX was further confirmed by Basic Local Alignment Search Tool (BLAST) of the obtained sequence with NCBI database. In addition, direct whole genomic sequencing on the vesicular fluid sample was performed by Oxford Nanopore MinION apparatus, obtaining 197,315 base pair sequence. The result indicates that the viral sequence shares higher similarity with the "West African" MPXV clade, including the European (Germany) and America lineages, rather than the "Central Africa" or Congo clade (Fig. 2 ). The accession numbers of Taiwan MPXV and other reference strains are listed in Fig. 2. 
The patient was admitted to a negative pressure room in a local teaching hospital on 23 June, 2022 for isolation. On admission, he had a temperature of 36  C, and a pulse rate of 87/min. His blood pressure was 125/92 mmHg. Examination revealed scattered pustules and vesicles over his face, limbs, trunk, genital, and perianal areas (Fig. 1 A-K). Lymphadenopathy was palpated over his inguinal areas, bilaterally. His white blood cell count was 9530/muL with neutrophil 45.7%, hemoglobin 15.5 g/dL, platelet count 276 x 103/muL, and a C-reactive protein level was 2.75 mg/dL. His renal and liver functions were within normal limits. A chest radiograph was negative for pneumonia. A nasopharyngeal SARS-CoV-2 PCR was positive with a cycle threshold of 37, and turned negative 3 days later. After conservative management, the patient remained well and his skin lesions began crusting by day 6 of admission (day 9 after onset). The patient was discharged on July 14, 2022 (day 25 after onset) with complete healing of skin lesions.