A 34-year-old man presented with a 2-day history of fever and mouth rash. He also noted headaches, oral pain and difficulties in swallowing. He also reported condomless intercourse with different new male partners during the past month. He had a personal history of sexual transmission disease, in particular genital infection by chlamydia and gonorrhea. Clinical examination showed bilateral latero-cervical lymphadenopathy as well as multiples mouth canker sores at the top of the tongue and the floor of mouth (figure). Those oral lesions harbor a cockade or “target-like” pattern with a central red ulcer surrounded by a white halo. He didn't present with any skin lesions. Polymerase-chain-reaction assays of swabs obtained from lesions on the tongue were positive for monkeypox. Notably, the patient was unvaccinated for the small-pox. Antimicrobial therapy for possible superinfection (amocicillin), local antiseptics (chlorheidine) general and local analgesics (paracetamol, xylocaine) were initiated.Within 2 weeks after his initial presentation, the patient's lesions had abated without specific intervention.
While classical symptoms are fever and swollen lymph node followed by a centrifugal evolving rash, atypical features have also been described. Thus, according to the World Health Organization, any person who presents with a rash with blisters on skin and/or mucosae (genital, peri-anal and buccal), fever, swollen lymph nodes, headaches, muscle aches and fatigue should get tested for monkeypox. As we observed in this patient, monkeypox cases can be pauci-symptomatic with a “cockade-like” rash in the oral cavity only, which can easily overlooked. Engaging all medical physicians performing oral examination in early detection of monkeypox cases should be set as a priority.
