Mpox-Induced Proctitis

Abstract

Introduction

Mpox, formerly known as monkeypox, is a zoonotic virus in the genus Orthopoxvirus, which has a variable incubation period and an extensive array of symptoms. While those infected with Mpox have displayed generalized viral prodromal symptoms, atypical symptoms such as proctitis have also been seen. Proctitis associated with Mpox is a relatively infrequent initial presenting symptom with a reported incidence of 14–32.9% that has seen an uptick in prevalence since the 2022 global endemic.

Case Presentation

We present a confirmed case of Mpox in a 27-year-old male who presented with 3 days of intermittent anorectal bleeding and various forms of cutaneous lesions at different stages of healing. He had engaged in unprotected sexual intercourse 8 days prior to the onset of his symptoms in New York, which at the time was the epicenter of the endemic. Computed tomography imaging showed thickening of the rectum with associated lymphadenopathy, consistent with findings of acute proctitis.

Conclusion

The intent of this case report is to acknowledge the prevalence of the Mpox virus. Since the endemic, increased cases of Mpox have led to more complications that have been identified and studied by public health experts. The complication of proctitis due to Mpox in a certain subset of patients is important to fully understand that while this virus presents with a generalized prodrome like other viruses, these unique gastrointestinal presentations and findings may be the first step in identifying this infection and ensuring rapid treatment if future endemics arrive.

Introduction

Mpox, known as monkeypox until the World Health Organization (WHO) renamed it, is an Orthopoxvirus that was first identified as a disease in humans in the 1970s and has been an endemic disease within Central and West Africa.¹ Though positive tests have been seen sporadically throughout the years, it was not until July of 2022 that WHO declared this outbreak a public health emergency of international concern, with tens of thousands of confirmed cases worldwide.¹ Mpox typically presents with a viral prodrome of fever, chills, headache, myalgias, and fatigue followed by a rash presenting 1 to 4 days later.¹

In this case report, we discuss a subset of patients who can present with an atypical clinical symptom of proctitis. Proctitis associated with Mpox is a relatively infrequent initial presenting symptom, with a reported incidence of 14–32.9% but has seen an uptick in prevalence since the 2022 global endemic.² We present a Mpox polymerase chain reaction-confirmed case of a 27-year-old male who presented with 3 days of intermittent anorectal bleeding and various forms of cutaneous lesions at different stages of healing. We discuss the atypical presentation of proctitis from Mpox and the importance of appropriate management to prevent further worsening and complications.

Case Presentation

A 27-year-old male presented to the hospital due to a 3-day history of anorectal pain, bloody stools, and multiple pustular lesions scattered across his body (Figure 1). His past medical history included testing positive for syphilis, which was treated appropriately in 2020. Eight days prior to the onset of his symptoms, during a 4-day trip to New York, he had unprotected anal intercourse with a male whose history of sexually-transmitted infections was unknown.

Figure 1.

A pustular skin lesion was seen below the left clavicle, consistent with skin findings seen in Mpox.

His first sign was a pustular-like lesion on his right eyelid. Over the following days, he sequentially developed anorectal pain and pressure during bowel movements, hematochezia, and additional lesions that developed sporadically across his body. On the third day of his symptoms, he began experiencing intermittent rectal bleeding without bowel movements and pruritic sensations on his flank and genital area where multiple lesions were present. The patient was suspicious of Mpox and decided to receive the Mpox vaccine 1 day prior to hospital admission, where his vitals were within normal limits. Due to the increased media attention on Mpox and its association with anorectal sexual intercourse, the patient felt that he was at high risk for the disease, prompting him to receive the vaccine. Additionally, he had right eyelid swelling and painless inguinal lymphadenopathy bilaterally. Due to his endorsed rectal pain, pressure, and bloody stools, the perianal area was examined where the skin was erythematous and lesions were visualized.

A proper swab of the lesions found on his chest and axilla was sent for polymerase chain reaction testing, and the patient was placed in isolation with droplet precautions. Due to his complaint of rectal bleeding, piperacillin-tazobactam was started empirically for possible bacterial proctitis and diphenhydramine was ordered for pruritis. During his hospital course, additional tests were negative for syphilis, gonorrhea, chlamydia, herpes simplex virus 1 and 2, hepatitis B and C, and human immunodeficiency virus (HIV). A computed tomography (CT) scan of the abdomen and pelvis was obtained and revealed splenomegaly and multiple enlarged lymph nodes adjacent to the rectum (Figure 2), moderate thickening of the rectum (Figure 3), and moderately increased soft tissue density in adjacent perirectal fat. A gastroenterology consult was considered; however, due to the resolution of the bloody stool and stable hemoglobin, as well as the patient’s wishes, further workup with colonoscopy or flex sigmoidoscopy was deferred to the outpatient setting.

Figure 2.

A computed tomography scan of the abdomen/pelvis showed perirectal lymphadenopathy (orange arrow).

Figure 3.

A computed tomography scan of the abdomen/pelvis showed perianal inflammation (orange arrow.)

By the end of the patient’s 3-day hospital stay, his Mpox serology was returned with a positive result. He was still presenting with newly formed lesions, though the old lesions were improving and began to crust. He denied rectal bleeding though did admit to continued anorectal pressure and discomfort. Given a positive test result, the final diagnosis of Mpox virus with associated proctitis was made. As the patient was not experiencing significant complications or severe disease, beginning antiviral medication was not indicated. His symptoms were self-resolving, and he was stable for discharge with instructions to cover his pustular lesions, avoid unprotected sexual contact, and continue to wear a mask until his lesions scabbed over.

Discussion

With the onset of the Mpox pandemic in the United States (US) in July 2022, clinicians have noticed more complications and atypical presentations of this viral process. In this patient, the atypical presentation was proctitis, which is not typically seen by this virus or its sister viruses, such as smallpox. The patient’s presentation with proctitis, with associated lymphadenopathy, likely arises from the entry of body fluid during sexual intercourse.³ The virus likely then spread from the local lymph nodes to the blood and, furthermore, to the skin where it presented as sporadic pustular lesions. The findings of regional lymphadenopathy adjacent to the rectum on CT have also been consistent with many individuals diagnosed with Mpox proctitis, making it a specific indicator of the disease. In the setting of anorectal intercourse, it is also important to assess and potentially rule out other sexually transmitted infections, including chlamydia, gonorrhea, syphilis, and HIV.^1,4

While a majority of cases of Mpox are self-limiting, some complications require hospitalization and, furthermore, pharmacological management.⁵ Indications for hospitalization include severe pain from skin lesions as well as complications, including proctitis, as in this patient, encephalitis, and secondary pneumonia.^4,5 In cases where symptoms are not improving, the patient may benefit from medical therapy. There is no specific antiviral therapy for the treatment of Mpox, but 2 medications, cidofovir and tecovirimat, have been approved for smallpox and have been shown to have some activity against Mpox.⁶ However, in this patient’s case, his symptoms improved with supportive care, and he did not require antiviral therapy.

The appearance of Mpox in the US has also brought forth concerns arising around post-diagnosis care. The patient’s hematochezia resolved during his hospital stay, but he continued to require isolation as he was symptomatic. Additional post-diagnosis care included instructions to cover parts of the skin that have lesions and performing intercourse with protection. It is important from a clinician’s standpoint to recognize and address the complications that arise from Mpox. Although these complications have been historically rare, the increase in patients suffering from this condition has all but guaranteed that more will be seen in the future.

Conclusion

We presented an atypical manifestation of Mpox-induced proctitis that included the commonly seen variety of cutaneous lesions. Mpox has been presented with lymphadenopathy, which distinguishes it from its sister viruses, such as varicella and smallpox. With the increase in prevalence of Mpox globally, there has been an increase in complications and atypical manifestations from this virus that clinicians should be aware of, such as gastroenterological manifestations. As this ongoing global outbreak continues, prompt identification is important to guide treatment, especially in cases where the suspicion is high.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.