A 28-year-old man who has sex with men presented with fever (37·8°C) and vesicles on the genital area and left cheek 10 days after unprotected sexual intercourse. At dermatological examination, erythematous rounded pustules 5 mm in diameter with central umbilication were located on the penile shaft and preputial groove, and a pustular vesicular lesion was located on the face above the left upper lip (figure ). Monkeypox virus infection was confirmed by PCR testing of swabs from facial and genital pustules. Monkeypox virus PCR of swabs from the upper respiratory tract, PCR of EDTA (edetic acid) blood, and urine samples were also performed, all of which tested positive for monkeypox virus. Biopsy on one of the non-facial pustules identified severe cellular necrosis and balloniform degeneration in the epithelium of the hair follicles (figure A).
Figure.
Verrucous monkeypox lesions
(A) Histopathology of a monkeypox pustule (haematoxylin and eosin): intraepidermal necrosis, marked oedema, dilated blood vessels, dense inflammatory perivascular infiltrate, and balloniform degeneration in the epithelium of hair follicles. (B) Hypertrophic facial monkeypox lesions. (C) Videodermatoscopy of hypertrophic facial monkeypox lesions after curettage. (D) Rounded erythematous monkeypox macules at day 62.
The patient was advised to isolate at home until resolution of the rash, and was prescribed 1000 mg paracetamol twice a day for 5 days. After 4 weeks, almost all of the lesions had healed. However, a new perioral pustule had developed near the first one and both lesions were topped with thick brown-coloured crusts that were difficult to remove. After nearly 6 weeks (on day 41), the skin rash had resolved except for these two perioral lesions, which also appeared to have a hypertrophic verrucous aspect and hard consistency on palpation (figure B). Consequently, we curetted the crusts. At this timepoint, monkeypox virus PCR of the lesions was negative and videodermatoscopy showed a homogeneous pink background colour, with crystalline white-coloured structures and curved vessels evenly distributed in the lesions indicative of an inflammatory pattern (figure C). At day 62, the lesions appeared to be blurred and were gradually reducing (figure D). Because of the delicate facial area and dermoscopic pattern indicative of autonomous resolution, we took a conservative approach and prescribed non-steroidal anti-inflammatory gel, containing sodium butyroyl formyl hyaluronate, panthenol, and tocopherol acetate, once a day for 3 months.
Declaration of interests
We declare no competing interests.
Contributors
BS made the diagnosis, managed the patient's treatment, contributed to data curation, drafted the original manuscript, and wrote this Clinical Picture. BMP contributed to writing this Clinical Picture. VG contributed to diagnosis, data curation, and writing this Clinical Picture. The patient provided written consent for the publication of this Clinical Picture.