Track
Case ReportsAbstract
Monkeypox (mpox) is a viral infection caused by an Orthopoxvirus, usually self-limited, but which can follow a severe and atypical course in immunocompromised individuals, leading to diagnostic and therapeutic challenges. We report a 26-year-old male with AIDS-stage HIV infection (CD4 38 cells/mm³, viral load 245,000 copies/ml), who initially presented to another facility with ulcerated scalp lesions. Biopsies revealed ulcerated eosinophilic folliculitis, prompting optimization of antiretroviral therapy and wound clinic follow-up. Despite these measures, he developed new ulcerated plaques on the left index finger and elbow. On admission to our institution, he exhibited large ulcerated plaques in the fronto-parietal and bilateral temporal regions, left index finger, and elbow, with raised, undermined, verrucous borders and abundant serous exudation. Differential diagnoses included pyoderma gangrenosum, tropical infections, and cutaneous neoplasms. The first institutional biopsy showed ulcerated skin with fibrin deposition and dense lymphoplasmacytic-histiocytic infiltrate; ZN, PAS, Gomory, and Gram stains were negative. Treponema pallidum and cutaneous leishmaniasis were also considered. Expert dermatopathology review identified hyperplastic squamous epithelium with viral inclusions (hyperchromatic nuclei, abundant eosinophilic cytoplasm), findings consistent with necrotic ulcer secondary to mpox. Given the unavailability of tecovirimat in our country, management consisted of optimized antiretroviral therapy (tenofovir/emtricitabine and dolutegravir) and multidisciplinary care, achieving marked viral load reduction, CD4 increase, and complete re-epithelialization of all lesions. This case underscores the atypical presentation of extensive, chronic cutaneous ulcers in mpox, the pivotal role of immune restoration in resolving atypical lesions in advanced immunosuppression, and the value of expert histopathologic review for timely and accurate diagnosis.