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Case ReportsAbstract
Monkeypox (mpox) is generally considered a self-limited Orthopoxvirus infection. However, in the context of profound immunosuppression, it can adopt an aggressive, rapidly progressive, and necrotizing form, leading to systemic complications. We report the case of a 40-year-old male with no prior medical history who presented with a 2-month history of painful erythematous plaques initially confined to the genital region. These lesions rapidly progressed to extensive ulceronecrotic plaques involving the face, trunk, upper limbs, pubic area, and perianal region, accompanied by fever, odynophagia, and dysphagia. Laboratory evaluation revealed newly diagnosed HIV infection (CD4: 35 cells/mm³, viral load: 670,000 copies/mL), PCR-confirmed mpox, and syphilis. The cutaneous findings were clinically interpreted as progressive mpox in the setting of advanced immunosuppression. Wound care was initiated, and antiretroviral therapy (tenofovir, emtricitabine, dolutegravir) commenced in the absence of tecovirimat availability. During hospitalization, the lesions evolved into confluent necrotic plaques with thick fibrinous exudate, purpuric perilesional halos, and vesiculobullous transformation. Particularly striking was the left index finger, showing complete de-roofing of a flaccid bulla with distal necrosis, cyanosis, and digital ischemia. Despite the initiation of Antiretroviral therapy and broad-spectrum antimicrobials, the patient experienced rapid deterioration, developing probable immune reconstitution inflammatory syndrome, septic shock, and multiorgan failure, culminating in death. This case highlights the fulminant dermatologic expression mpox can reach in severely immunocompromised hosts and underscores the clinical complexity of managing such patients. It further emphasizes the unpredictable interplay between viral pathogenesis, advanced immunosuppression, and co-infections, even when appropriate therapy is promptly instituted.