Case Presentation
A 32-year-old HIV-positive man who has sex with men (MSM) presented to emergency department with a two-day history of a firm, painless solitary chancre-like nodule on lower lip (Figure 1A), associated with tender bilateral cervical lymphadenopathy in the absence of other systemic symptoms. The patient reported practicing unprotected receptive oral sex 3 weeks before. He re-consulted 2 days later due to the onset of tenderness and swelling of the lower lip with associated fever. Physical examination then revealed lesion enlargement and ulceration as well as development of clustered satellite papules on labial mucosa (Figure 1B). A polymerase chain reaction (PCR) of swabs obtained from the ulcer and pharynx were positive for monkeypox virus (MPXV). Performed venereal disease research laboratory (VDRL) and Treponema pallidum particle agglutination (TPPA) tests were repeatedly negative. Bacterial cultures obtained from the ulcer, pharynx and rectal swabs were all sterile.
Figure 1.
(A, B) Solitary, firm, chancre-like painless nodule on the lower lip (A), subsequent physical examination revealed enlargement and ulceration of the lesion as well as development of clustered satellite papules on labial mucosa (B).
Teaching Point
Because of shared risk factors and similar incubation period, it is reasonable to include MPXV infection in the differential diagnosis of primary syphilis in patients at risk presenting with a solitary lesion in the oral or genital regions. This has already been suggested in two recently published case reports [1,2].
In this scenario, it may be useful looking out for the presence of pain and edema in the involved region, development of satellite papules as shown in this case or the appearance of painful lymphadenopathy, all of them pointing to the diagnosis of MPVX infection, with PCR being the diagnostic test of choice.
The patient in this manuscript has given written informed consent to publication of his case details.
Footnotes
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Funding: None.
References
- 1.Turco M, Mancuso FR, Pisano L. A monkeypox virus infection mimicking primary syphilis. Br J Dermatol. 2022;187(6):e194–e195. doi: 10.1111/bjd.21847. [DOI] [PubMed] [Google Scholar]
- 2.Ramoni S, Maronese CA, Morini N, et al. Syphilis and monkeypox co-infection: Coincidence, synergy or asymptomatic carriage? Travel Med Infect Dis. 2022;50:102447. doi: 10.1016/j.tmaid.2022.102447. [DOI] [PMC free article] [PubMed] [Google Scholar]