Monkeypox coinfection with Neurosyphilis in a transgender with HIV in Atlanta, USA

1. Introduction

Monkeypox was first diagnosed in the 1970s in Central Africa and has been predominantly found in the African subcontinent until recently [1]. In May 2022, WHO reported Monkeypox outbreaks in non-endemic regions, including the US, Europe, and Australia, among patients with no travel history to endemic areas [2], predominantly seen among men who have sex with men (MSM). The primary human-to-human transmission route is via close contact with respiratory secretions, skin lesions, or recently contaminated objects [3]. Symptoms last 2–4 weeks, most commonly fever, headache, lymphadenopathy, and a characteristic rash often on the face and extremities.

Recent pooled data analysis revealed that several cases during the current outbreak had been reported to have anogenital lesions and rashes sparing the face and extremities [4]. Interestingly, headache has been the presenting symptom in up to 25% of subjects [4]. The age group of individuals in the current outbreak has been noted to be predominantly younger, in their thirties [4]. The most common transmission route reported is intimate contact, although it is currently unknown if the virus spreads through semen or vaginal fluids [5].

Our case report describes the concurrent infection of Monkeypox and Neurosyphilis in a patient with HIV.

2. Case description

A 34-year-old Male-to-Female transgender patient with HIV on Anti-Retroviral Therapy (ART) presented to the Emergency Department in Atlanta, Georgia with headache and fever for six days. The patient also complained of photophobia, neck stiffness, and bilateral lower extremity weakness for four days. She denied cough, sore throat, or dysuria or skin rashes. Her last CD4 count was 200 about two months before presentation, and she was non-compliant with ART. Last sexual activity was a few days before admission, and she had four male sexual partners in the past six months. She denied sick contacts or recent travel history.

The patient was febrile on arrival to 39.4C. She also had hyponatremia of 132, and a normal white blood count. There were no focal neurological deficits on the physical exam. A CT head imaging was normal. A lumbar puncture was performed, and blood cultures were ordered. The patient was started on empiric vancomycin, ceftriaxone, ampicillin, and dexamethasone for suspected meningitis and was admitted to the hospital.

CSF cell counts revealed mild lymphocytosis of 100, normal nucleated and red cell counts, concerning for aseptic picture. Empiric antibiotics were discontinued. However, given the unexplained lower extremity weakness, an MRI Head was obtained, which was normal. CSF HSV PCR and CSF cryptococcal Antigen testing resulted negative. Toxoplasma IgM and IgG, CSF HSV RNA, CMV DNA, and VDRL were negative. EBV DNA by PCR and IgM were negative, although EBV IgG was positive, signifying a past infection. Sexually Transmitted Infection (STI) panel was obtained. Rapid Plasma Reagin (RPR) returned newly reactive at 1:64, signifying a new infection. Since CSF pleocytosis was not very pronounced and CSF VDRL was negative, given a compatible clinical syndrome without an alternative explanation, it was determined reasonable to proceed with treatment for Neurosyphilis. In consultation with an Infectious Disease specialist, patient was started on treatment for Neurosyphilis with penicillin 4,000,000 IV every 4 h for fourteen days.

On day four of admission, patient developed pain in the rectum along with four maculopapular lesions in perianal region with tenderness to palpation. Empiric treatment for Gonorrhea and Chlamydia was administered with IV Ceftriaxone and Doxycycline, while awaiting STI results. The following day, lesions were found to evolve with umbilication and swabbed for Monkey Pox DNA PCR, which returned positive. Infection control was notified, and isolation precautions were placed. Antiviral therapy with Tecovirimat (Tpoxx) was considered beneficial given immunosuppression and concern for disease progression. The patient's lower extremity weakness significantly improved during the course, and the proctitis resolved. She was discharged on Tecovirimat for 14 days and to continue treatment of Neurosyphilis and was advised to follow up in primary care clinic and the Infectious Disease clinic. She was advised to isolate and avoid sexual contact until the lesions scab off, and symptoms completely resolve.

3. Discussion

The initial days of illness are critical to identify monkeypox and institute proper isolation procedures to prevent further transmission. Fig. 1 and Fig. 2 This patient's course was complicated by presentation with multiple systemic infections with overlapping symptom presentations, which may have delayed identifying pertinent symptoms and earlier diagnosis. Because no skin lesions were initially reported, the patient's clinical presentation for monkeypox may have been obscured by symptoms of Neurosyphilis.

Fig. 1.

Day 1 of lesions.

Fig. 2.

Day 2 of lesions.

It is known that symptomatology with the highest sensitivity (≥80%) for monkeypox are lymphadenopathy, fatigue, and the characteristic rash, while symptoms with high specificity include nausea, conjunctivitis, and genital lesions [6].

As there are no current guidelines in place for screening, and testing is currently only done for symptomatic patients, an argument could be made for more routine screening in at-risk, vulnerable populations, such as HIV/AIDS patient populations, to prevent community transmissions [7]. Although monkeypox is not considered contagious during the incubation period and asymptomatic monkeypox infection has not been documented, earlier identification would aid in timely containment [7].

This patient was of a particularly vulnerable population at risk for superimposed infections during a global outbreak. She had poor adherence to anti-retroviral medications that put her at increased risk for re-infection of syphilis and newly acquired monkeypox infection.

4. Conclusion

Suspecting monkeypox during the prodromal stage is necessary, especially in high-risk populations. Screening for co-infections is also highly beneficial, as sometimes the co-infections could mask the symptoms of monkeypox. Further studies are needed to determine the need for routine screening for monkeypox in high-risk populations.

Sources of funding

None.

Declaration of competing interest

None.

Abbreviations

HIV

Human Immunodeficiency Virus

WHO

World Health Organization

MSM

Men who have sex with men

DNA

Deoxyribose Nucleic Acid

ART

Anti-Retroviral Therapy

COVID-19

Coronavirus Disease

CT

Computed Tomography

CSF

Cerebrospinal Fluid

PCR

Polymerase Chain Reaction

CMV

Cytomegalovirus

EBV

Ebstein Barr Virus

VDRL

Venereal Disease Research Laboratory

RNA

Ribose Nucleic Acid

CDC

Centers for Disease Control and Prevention

RPR

Rapid Plasma Reagin

PICC

Peripherally inserted central catheter

STI

Sexually Transmitted Infection

IM

Intramuscular

IV

Intravenous