Case Presentation: The first patient is a 47-year-old African-American male who presented with severe hand pain and purulent wound. Initial laboratory findings revealed elevated liver enzymes, elevated inflammatory markers, and leukocytosis. The patient underwent incision and drainage of the hand wound followed by antibiotic administration. The patient then developed diffuse, pustular lesions with an umbilicated center on the trunk and bilateral upper and lower extremities. The patient subsequently admitted to recent skin-to-skin contact with many individuals at a pool party who were previously exposed to monkeypox. Three lesions were deroofed and swabbed, and PCR testing returned positive for all lesions. The patient was treated with supportive care and discharged home with isolation instructions and health department follow-up.The second patient is a 33-year-old HIV positive African-American male who presented with fever, chills, and severe rectal pain. The patient reported having a recent anal swab positive for gonorrhea. The patient also reported recent skin-to-skin contact with multiple individuals along with sharing of towels and bed linens. The patient exhibited a diffuse, pustular rash on all extremities and trunk which were swabbed and resulted as positive for monkeypox PCR. Syphilis testing also returned positive. The patient was treated for gonorrhea and late latent syphilis and isolated for monkeypox. His constitutional symptoms resolved, and the patient was discharged with isolation instructions.The third patient is a 36-year-old Hispanic male who presented with complaints of painful defecation and difficulty urinating. A urine nucleic acid amplification test for gonorrhea was positive. Imaging revealed circumferential rectal and anal wall thickening. Exam under anesthesia exhibited several perianal and anal canal lesions. Shave biopsies showed ulceration and necrosis with cultures growing multiple bacterial species. The patient then developed a diffuse, maculopapular rash which tested positive for monkeypox. The patient was isolated and treated for underlying bacterial infections based on perianal lesion cultures. The patient’s clinical status improved, rash began to resolve, and the patient was discharged with isolation precautions.
Discussion: Human monkeypox is an emerging worldwide healthcare phenomenon. The World Health Organization (WHO) recently declared monkeypox a public health emergency of international concern. The previous rarity of monkeypox and the variations in clinical manifestations make monkeypox a diagnostic challenge. Monkeypox is an orthopoxvirus that may present similar to varicella or smallpox with a diffuse vesicular or pustular rash. Mortality among adults with monkeypox disease is as high as 10% if untreated. Most of the world population was previously partially protected against serious clinical manifestations through cross-immunity from smallpox vaccination. However, since the eradication of smallpox, which was certified by the WHO 40 years ago, and the cessation of routine vaccination against smallpox, monkeypox has begun to re-emerge.
Conclusions: This case series of community-acquired monkeypox emphasizes the clinical signs and symptoms, prodromal manifestations, importance of a thorough and complete social history, diagnostic techniques, treatment options, and current requirements for isolation to prevent further community spread.