A case report of pedal monkeypox in a HIV patient: A challenging diagnosis with a misleading history

Abstract

Pedal Monkeypox is a disease which can mimic many other pedal conditions. It should always be considered in differential diagnosis. A young male HIV patient who presented with a tender foot lesion and diagnosed with pedal Monkeypox as a result of performed tests is discussed hereby in the case report. We expect that this case report adds to the existing literature on this subject.

Introduction

Monkeypox is a rare disease caused by infection with the monkeypox virus. Monkeypox virus is part of the same family of viruses as variola virus, the virus that causes smallpox. Monkeypox is not related to chickenpox. The first human case of monkeypox was recorded in 1970. Prior to the 2022 outbreak, monkeypox had been reported in people in several central and western African countries. Previously, almost all monkeypox cases in people outside of Africa were linked to international travel to countries where the disease commonly occurs or through imported animalskin.¹

Most infections during the current outbreak have been transmitted through close, intimate contact with symptomatic people, primarily during sexual contact.The majority of infections have been transmitted among men during male-to-male sexual contact,² however heterosexual sexual transmission, transmission to children through close non-sexual skin-to-skin contact with a caregiver, and transmission through needlestick with a skin lesion-contaminated sharp as well as through piercing and tattooing, have also been reported.^{3 , 4}

Case report

A 38 years old male patient with a medical history of HIV, bipolar disorders, asthma, anemia, medication non-compliance was brought to our emergency department by ambulance with a tender right foot wound associated with redness, swelling. In the initial encounter, Patient reported that he was walking around barefoot outside on a wooden deck 3 days ago and developed worsening right foot pain which he has not experienced before. He reported noticing a dark area and small hole on the plantar surface of his foot. He did not recall stepping on anything or puncturing his foot. Patient denied fever, nausea, vomiting, chest pain, shortness of breathing, weakness, numbness, headache, he also denied rash in any other body parts. Patient reported that he's receiving Biktarvy, and his last CD4 count in April was below 100. However, he is not compliant with taking his medications.

On physical examination, the right foot showed a puncture-like wound noted to the plantar medial aspect of the forefoot, moderate edema and erythema noted with dry hematoma noted underneath. No drainage or malodor noted. Pedal pulses were non-palpable secondary to edema, CFT< 3 s. with increase in temperature gradient from the contralateral side. Protective sensation was intact revealed by the Ipswich exam. Superficial bedside incision and drainage was performed and the subcutaneous hematoma was evacuated and flushed with a mixture of betadine/sterile saline solution. It was then decided to admit the patient for intravenous antibiotics administration and further vascular and medical work up.

The patient over the course of the next few days had developed swelling in the area of initial injury, with associated pain out of proportion.The initial cultures grew back MRSA. Infectious Disease as well as the primary team were concerned for necrotizing fasciitis or compartment syndrome due to this clinical appearance. The decision was made to take the patient to the operating room for a decompression fasciotomy. Intraoperatively, the fasciotomy show all muscle and soft tissue healthy with no signs of gross compartment syndrome, there also was no pus or fluid collection noted. Blood return was sluggish to the lower extremity. The decision was made to only utilize one incision as it was sufficient in releasing all compartments necessary. The site was left partially open with 2–0 nylon retention sutures At this point it was noted that the patient had vesicular lesions on his hands.

After the fasciotomy, the patient was further asked about these lesions which revealed him stating he had previously recovered from a bout of monkeypox. The patient's CD count was also discovered to be <20 from lab results. The patient was tested for Monkeypox and it showed that he was positive for Monkeypox-CLADE 2 (West African Variant). A further history was obtained and the patient stated that he thought the monkeypox was resolved since he could not see any more lesions. He was only treated for 12 days with Tpoxx prior to admission. The patient's extremity over the course of the week started to become more inflamed and showed necrotic changes of the skin itself. Blistering similar to monkeypox, only in cluster formation, started to appear and envelop the whole foot. Over time this blistering has been replaced with necrotic tissue and eventual demarcation of the area, as found in how a monkeypox lesion would look. This specific presentation is shown to be en masse enveloping nearly the entire foot. The patient is currently on: TPoxx, IVIG for his monkeypox, Bactrim, Daptomycin and Meropenem for any potential bacterial infections and Tivicay and Truvada for his AIDS. His-prognosis is still being monitored.

Discussion

The calling card of monkeypox is a vesicular outbreak that starts as a macular rash and then becomes a vesicular-pustular papule. At the height of the rash the anti-inflammatory IL-10 is found to be produced in extreme amounts. In combination with this if > 250 lesions are present this anti-inflammatory, which is now coded from the monkeypox instead of naturally, can actually have the reverse effect, causing extreme inflammation.⁵ With this change, tissue necrosis can occur and therefore secondary infections can become prevalent. Due to the nature of this there have deep cases with monkeypox cause deep seated cellulitis and abscesses.^{6 , 7} Location of these lesions are important as well, mainly occurring on the genital area, however a study showed that 50% of lesions also occurred on the extremities, with 20% occurring specifically on the lower extremities.7 In a case series done, Monkeypox with a concurrent AIDS infection shows that severe symptoms , although uncommon, cannot be overlooked. This showed that about 30% of all AIDS patients received some sort of ICU treatment and of those succumbed to their illnesses.⁸ One specific case showed a similar pattern to a lesser extent of the patient being non-compliant with TPoxx medications and presenting with coalescing Monkeypox on the hands and feet , eventually requiring a debridement and amputation of the 4th digit of his toe.⁸ Monkeypox's calling card is a vesiculopapular rash that forms necrosis later on. The histopathology from a case report in 1985 shows that the necrosis forms at the stratum basale and the next 2–3 layers up into the stratum spinosum.⁹ However, there hasn't been much literature to see histopathology at a deeper level, like muscle. This is mainly due to Monkeypox being mostly limited to the cytoplasm of the dermis and epidermis, the latter showing abundant immature and mature orthopoxvirus particles in the cytoplasms of infected epidermal cells.⁹

Conclusion

Monkeypox has recently been brought to the forefront due to its recent outbreak. This case report hopefully can shine a light on multiple topics: For starters, the sequelae of trauma to an area of infection with the virus. Intraoperative findings of the virus itself when performing a fasciotomy, and the importance of a quick recognition and thorough history, even with different misleading factors in asymptomatic stages.

Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5

Fig. 1.

(A) Initial Presentation of Wound, (B) and (C) Initial Incision and Drainage of Wound.

Fig. 2.

(D) and (E) results 1 day status post Fasciotomy .

Figs. 3.

(F,G,H) weeks status post fasciotomy.

Fig. 4.

(I) Left foot initial presentation of monkeypox lesion (this lesion had the sequelae of a normal monkeypox as it was left undisturbed).

Fig. 5.

(J,K,L,M) most recent presentation, about 2 months status post fasciotomy, demarcation of dermal necrosis noted.

Financial disclosure

None Reported

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.