Case Presentation: A 35 y/o male with HIV infection presented with 3 weeks of worsening perianal pain. Patient reports engaging in receptive anal and oral sex approximately 3 weeks ago, with inconsistent condom use. He developed both perianal pain and skin lesions a few days after the encounter, noting vesicular and umbilicated lesions in his face and perianal region, as well as rectal pain exacerbated with defecation. Patient was seen at an outside urgent care facility 1 week ago, and was given a combination of cephalexin and acyclovir for presumed HSV with superimposed cellulitis which were ineffective. He reports being off antiretroviral therapy for the past month.Exam demonstrated numerous perirectal pustular lesions and umbilicated lesions on the right hand. Patient met sepsis criteria with fever of 38.7, tachycardia of 134 bpm, and white blood cell count of 15.8. He was initially given ceftriaxone and doxycycline in the ED, and later was escalated to piperacillin-tazobactam. HSV PCR and gonorrhea and chlamydia were negative, and 3 of 3 monkeypox PCR specimens from superficial swabs from his rectum and hand returned positive. CD4 count was 179 and HIV VL 888. CT of the abdomen and pelvis demonstrated multiple perianal abscesses, the largest 2.6 cm in diameter in addition to extensive lymphadenopathy.Patient was hospitalized for further management. Infectious Disease started tecovirimat for monkeypox General Surgery incised and drained the two largest of the patient’s perirectal abscesses, both of which were returned positive for E. coli on culture. Blood cultures ultimately returned negative.Our patient’s sepsis improved, but he had persistent rectal pain. Patient unfortunately left against medical advice on the fourth day of hospitalization, citing poor pain control as his reason for leaving. His remaining tecovirimat was brought to bedside for him.

Discussion: Monkeypox is zoonotic disease caused by an Orthopoxvirus endemic to West and Central Africa, but the recent 2022 outbreak and rapid spread of the disease outside endemic areas have suggested a new pattern of human-to-human transmission. Men that have sex with men and members of the LGTBQ community appear to be particularly affected. Recent retrospective studies have identified HIV patients at significant risk for extensive perianal vesicular umbilicated lesions with different morphologic phases.This case illustrates the characteristic extensive involvement of perianal and rectal lesions secondary to monkeypox infection, as well as the possibility of superimposed bacterial infection, which, in the setting of his suboptimally controlled HIV led to E. coli abscesses and sepsis. A recent large case series of 528 infections since the start of the 2022 outbreak noted the soft tissue superinfection complicating only 18 such cases, 3.4% overall [2], but early suspicion of monkeypox and its potential complications and prompt initiation of antiviral treatment (tecovirimat) as well as antibacterial treatment, when indicated, are paramount for clinical improvement.

Conclusions: Monkeypox in HIV positive patients is particularly characterized by rectal and perianal extensive involvement. Complications such as bacterial superinfection, with resulting abscess formation and sepsis, can also be seen, especially in the setting of immunocompromised. Early recognition of the clinical features in at-risk populations and prompt initiation of appropriate therapy can result in clinical improvement.