Case Presentation: Case Presentation:A 36 year-old male with a history of HIV adequately controlled with Biktarvy and recent monkeypox infection presented with acute onset of rapidly ascending lower extremity paralysis. He presented to the ED for primary concern of severe left upper quadrant and back pain. He also noted bilateral lower extremity numbness below the knees but was able to ambulate. He progressed over the course of 24 hours from numbness below the knees, to significant weakness, to full flaccid paralysis with loss of sensation to dermatome at T2 and urinary retention. In addition to monkeypox infection starting 5 days prior, patient also noted a history of syphilis infection within the past 6 months treated with penicillin and a flu vaccination 10 days prior. He also endorsed marijuana use and high-risk sexual activity. Patient had an MRI spine to workup bilateral numbness which revealed nonenhancing T2/FLAIR changes from T1-T10. MRI brain showed nonenhancing T2/FLAIR hyperintensities within the left external capsule, right middle cerebellar peduncle, left cerebellar white matter and pons. Lumbar puncture showed leukocytosis with lymphocytic predominance, elevated protein and negative meningitis and encephalitis panel. Evaluation for demyelinating processes, autoimmune encephalitis, neurosyphilis, among other etiologies were all negative. The patient was continued on oral tecovirimat therapy for 14 days. He was treated with 5 days of high dose methyl prednisone followed by 5 days of IVIG without any improvement. Plasma exchange (PLEX) therapy for was initiated a week after the last dose of IVIG for 5 alternating treatment days. Sensation quickly improved to the level of T12. He had small improvement in knee extension during intensive physical therapy over the next 2 weeks. His hospital course with complicated by ileus, pulmonary embolism despite prophylactic anticoagulation, and suicidal ideation.
Discussion: Discussion:Following the identification of the first case of monkeypox outside of West Africa since 2003 on May 7th 2022 (1-2), nearly 70,000 cases of monkeypox have been identified globally (3). Throughout the outbreak, the vast majority of cases were found in male-identifying individuals under the age of 35 who report having sex with men (3). As was this patient, nearly 50% of reported cases have been in HIV-positive individuals (3).The neuroinvasive potential of monkeypox has been documented with reported manifestations including encephalitis, seizures, transverse myelitis and other neuropsychiatric complaints (4-7). These complications are exceedingly rare, though the potential impact on patient morbidity and mortality is significant. Other patients with similar neuro manifestations of monkeypox also experienced improvement following PLEX therapy (7). Identifying appropriate immunotherapies for long-term maintenance or continued neurologic improvement will require continued research.
Conclusions: Conclusions:Given the new outbreak of monkeypox, internists must be prepared to counsel patients, diagnose and treat neurologic manifestations of this infection.