Genital infection from Monkeypox virus requiring surgical debridement and scrotoplasty in an immunocompromised patient

Abstract

Background

Mpox is a zoonotic viral disease transmitted by close contact with infected individuals, contacting or eating infected animals, and now, sexual contact. The main treatment option for infected individuals is supportive care as no FDA-approved treatment exists.

Case presentation

A 33-year-old male with HIV who contracted Mpox who developed a large painful genital ulcer with overlying eschar. He required surgical debridement of the penile ulcer followed by scrotoplasty.

Conclusion

While local wound care plus antibiotics may be effective at managing some genital lesions, Urologists should consider surgical debridement with delayed reconstruction for progressive, non-healing wounds in these individuals.

1. Introduction

Mpox, formerly known as Monkeypox, is a zoonotic viral disease of the orthopoxvirus family transmitted from human to human via close contact with skin lesions, droplets, or fomites.¹ There are currently 29,913 US and 84,318 cases world-wide.² Risks factors consist of travel to endemic areas, providing care to an infected animal, and sexual transmission.¹ Initial presentation for mpox may include fever, chills, lymphadenopathy, fatigue, and other viral-like symptoms.³ Skin lesions develop around mucosal surfaces including the genital and perineal regions.³ Lymphadenoapthy can be seen based on the location of the lesion. Penile shaft lesions/ulcers drain to the superficial inguinal lymph nodes. Lesions of the glans will drain to the deep inguinal nodes. There are currently no standard treatment protocols for Mpox.⁴ Supportive symptomatic care and local wound treatment is advised with cidofovir and tecovirimat.⁴ This is a case report of the first report of Mpox virus affecting the genitals that required surgical intervention.

2. Case presentation

Our patient is a 33 year-old male with a past medical history of HIV (human immunodeficiency virus) on Genvoya who presented to the emergency room for a painful penile ulcer. He originally presented to the infectious disease clinic and was treated empirically with Doxycycline while Mpox PCR was sent for diagnostic testing. The PCR was eventually positive for Mpox. Of note, his recent CD4 count is 140 with viral load of 319. Tecovirimat improved all the lesions, except for the penile lesion, thus, he presented to the emergency room.

Urology was consulted to evaluate his penile lesion. He denied fevers, chills, dysuria, hematuria, and foul-smelling discharge or urine. He was previously sexually active with men. Physical exam was notable for a circumcised male with an ∼4 cm eschar with rim of ulceration that located in the right mid penile shaft without any purulent drainage. There was also surrounding woody induration and penile edema extending to the base of the penis. Testes were bilaterally descended without any masses or tenderness to palpation no scrotal erythema, edema, fluctuance or necrosis. He had other partially healed umbilicated lesions over his head, trunk, and upper extremities, consistent with Mpox. A computerized tomography (CT) scan was obtained that showed a subcutaneous fluid collection measuring 1.5 x 1.3 × 1.1 cm at the penile base with enlarged inguinal and iliofemoral lymph nodes bilaterally including a 1.7 cm right inguinal lymph node with central necrosis/possible abscess. The Infectious disease service started the patient on empiric Vancomycin, Ceftriaxone, Flagyl for concern of superimposed deep bacterial infection, and Tecovirimat 600 mg q 12 with the plan to transition to his home Temcovirimat (TPOXX).

Given the dry gangrene, absence of palpable abscess and absence of purulent drainage at presentation, initial conservative approach was taken with local wound care and serial penile exams. After 3 days, he continued to have pain and the margins of the ulceration were well demarcated and there was separation between the surrounding skin and eschar. Therefore, the patient was recommended to undergo excision and debridement of the necrotic penile tissue. The wound bed initially measured 4.5 x 6.0 × 0.5 cm (Fig. 1). After the eschar was unroofed, it became apparent that the subcutaneous tissues were also nonviable and they were excised until healthy, bleeding tissue was encountered. The corpora and urethra were inspected and noted to be uninvolved and healthy. The final wound bed measured 9.0 x 6.0 × 2.0 cm. A wound vac was placed to facilitate healing.

Fig. 1.

Penile necrotic lesion on presentation prior to operative excision and debridement.

After 48 hours, he was brought back to the operating room. The wound measured 8.0cm × 5.5cm and the tissue was healthy, Acell powder was applied to the scrotal wound bed. Scrotal flaps were fashioned and a scrotoplasty was performed to close the inferior portion of the wound and provide recreation of the penoscrotal angle and good cosmesis. The A-Cell sheet was placed over the remaining penile shaft open wound and covered. (Fig. 2). He was sent with a 7-day supply of levofloxacin to continue to treat the Pseudomonas. At four weeks post operatively his wound was healing nicely and by his visit at 10 weeks post operatively it was completely healed with a good cosmetic result. (Fig. 3).

Fig. 2.

Penile lesion after scrotoplasty and A-cell placement (left) and 48 hours from initial debridement after removal of wound vac (middle).

Fig. 3.

Follow up in-office appointments showing well-healing lesions, 4 weeks (left) and 10 weeks (right) post-operatively.

3. Discussion

Mpox for most individuals is self-limiting and has an indolent course.⁴ However, immunocompromised patients have an increased risk of transmission, but also a more complicated clinical course.⁴ Supportive care for many individuals is typically sufficient. In complex patients, that are unresponsive to conservative measures, antivirals (e.g. tecovirimat, brincidofovir, cidofovir) and vaccinia immune globulin intravenous (VIGIV) are available as treatments.⁵ The Urologist should also be aware that GU lesions can become infected and warrant surgical debridement. As with penoscrotal wounds such as Fournier's gangrene, the authors recommend patients be monitored closely and reassessed daily to determine if repeat debridement is indicated. Once all debridement is complete, and the wound bed is without further infected or necrotic tissue, reconstruction can be undertaken with consideration to defect size, surrounding tissue availability and surgeon comfort level to include split thickness skin graft (STSG), primary flap closure, healing by secondary intention, or delayed primary. Products that promote epithelialization (such as ACell) should also be considered.

There are few cases of Mpox with significant involvement of the genitals,³ and even less that required extensive surgical interventions. Given this rare presentation, Urologists should use the basic tenets of penoscrotal infections and reconstructive surgery when future patients with Mpox and penoscrotal involvement require surgical intervention. Our patient was followed for 3 months post-operatively and was not exhibiting any of these complications at the time this case report was submitted for publication. All lymphadenopathy resolved on physical exam.

4. Conclusion

This is the first known case report of a Mpox virus infection that involves the genital region requiring surgical debridement. Physicians should be aware of this genitourinary presentation of the virus and include this diagnosis in their differential of genital lesions. Treatment requires multi-specialty care with Infectious disease and wound care with the possibility of surgical debridement being discussed, especially if wounds exhibit delayed healing, persistent pain, and/or progression to exhibiting signs of infection.