Rectal shedding of monkeypox virus in a patient coinfected with Chlamydia trachomatis and Neisseria gonorrhoeae: a case report

Florian Desgranges, Emmanouil Glampedakis, Vanessa Christinet, Sara Encarnação, Cândida Fernandes, Gilbert Greub, Onya Opota, Matthias Cavassini

Infection by the monkeypox virus classically causes a cutaneous rash that is preceded by fever and lymph node swelling, as well as other nonspecific systemic symptoms. A recent outbreak occurred and spread in Europe and other regions, especially among patients who declare themselves as men who have sex with men. Current reports have shown that cutaneous lesions may be limited to the anogenital area. We report on a case of proctitis caused by monkeypox virus, without visible typical lesions of this virus. A 29-year-old Caucasian male presented with a monkeypox virus proctitis that recurred after treatment for a documented Neisseria gonorrhoeae and Chlamydia trachomatis coinfection, likely acquired at the same time. The proctitis was preceded by fever and a swollen inguinal lymph node, and was associated with a hemorrhoid. The monkeypox virus polymerase chain reaction of a rectal swab documented high viral loads, although no typical lesion was visible. After resolution of the rectitis, the patient developed a single dermatome herpes zoster, despite the absence of usual risk factors. The patient evolved well without further specific treatment. This case shows that monkeypox virus can be responsible for proctitis, without any typical lesion, along with the important rectal shedding of the virus. It raises the concern of contagion during anal intercourse through body fluids and gives further credit that monkeypox virus can be a sexually transmitted infection. This should prompt routine rectal screening in patients with proctitis accompanied by fever and swollen lymph nodes, and in patients who have a history of unprotected receptive anal sex, even in presence of other sexually transmitted infections, and especially during a monkeypox virus outbreak. The potential link between monkeypox virus infection and shingles warrants further investigations.