Mpox (Monkeypox) with atypical clinical presentation and distinctive dermoscopic findings

IF 2.3 4区 医学 Q2 DERMATOLOGY
Yng Sun, Wei-Yao Wang, Kuan-Yu Chu, Cheng-CheE Lan, StephenChu-Sung Hu
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He had recently received a diagnosis of acute tonsillitis at the otolaryngology clinic and was treated with amoxicillin/clavulanic acid. However, the symptoms did not improve, and a few vesiculopustular lesions developed on the distal parts of the limbs, starting from the left palm and progressing to the left forearm and legs. Physical examination showed exudative and swollen left tonsil, tender left cervical lymphadenopathy, and asynchronous skin lesions comprising crusted lesions on the left palm and forearm and pustules with perilesional erythema on the left hand and legs [Figure 1a-f]. Polarized dermoscopic examination revealed homogeneous brownish coloration for the left palm-crusted lesion, brown-to-red central crust with peripheral erythema for the left forearm-crusted lesion, and central homogeneous yellow area surrounded by bright erythematous halo (resembling “rising sun”) for pustules on the left hand and legs [Figure 2a-f]. The torso and anogenital region were spared.Figure 1: Clinical images. (a) Swollen left tonsil with whitish-yellow exudate was noted on examination of the oral cavity. (b and c) Crusted lesions on the left palm and forearm. (d-f) Pustules with perilesional erythema on the left hand, ankle, and bilateral knees.Figure 2: Polarized dermoscopic images. (a) Homogeneous brownish coloration for the left palm-crusted lesion. (b) Brown-to-red central crust with peripheral erythema for the left forearm-crusted lesion. (c-e) Central homogeneous yellow area surrounded by bright erythematous halo for pustules, resembling “rising sun,” on the left hand, ankle, and knee. (f) Homogeneous yellow coloration with a central crust and mild peripheral erythema for the pustule on the right knee.Travel and contact history revealed that the patient had not traveled abroad recently but had engaged in unprotected oral sex with another man 2 weeks before the onset of the symptoms. Laboratory analysis revealed leukocytosis (13610/ul), elevated C-reactive protein level (15.49 mg/L), and a normal CD4 cell count (1003 cells/mm3). The HIV viral load was undetectable. Serological tests for herpes simplex virus (HSV), varicella-zoster virus, and syphilis were negative. Due to suspicion of mpox based on clinical features and epidemiologic criteria, real-time polymerase chain reaction tests on viral swabs from the pharynx and vesiculopustular fluid were conducted. The results confirmed the diagnosis of mpox (the cycle threshold (Ct) values were 36 and 24, respectively). He was then admitted to a negative pressure isolation room, and supportive care was provided. No new-onset vesiculopustular lesions were seen thereafter. All skin lesions had become crusted 2 weeks after admission, and the patient was discharged. Mpox is characterized by a prodromal phase of fever, constitutional symptoms, and lymphadenopathy, followed by an eruptive phase of centrifugally evolving macules, papules, vesiculopustules, crusted lesions, or ulcers, which can present simultaneously or at different stages of evolution.[1–4] The most frequently affected cutaneous areas include the anogenital area, followed by the trunk/limbs, face, and palms/soles.[1,2] Mucosal lesions occurred in approximately 41% of patients, mostly presented in the anogenital area.[1] Oropharyngeal symptoms, such as oral or tonsillar lesions and pharyngitis, as presenting symptoms are uncommon, observed in only 5% of patients.[1] Mpox is mainly transmitted through sexual close contact with infected individuals, especially MSM.[1,2,5,6] In our patient, the prodromal symptoms of sore throat with left cervical lymphadenopathy may suggest that the virus enters oral epithelial cells through receptive oral sexual exposure and then replicates in the cervical lymph nodes with subsequent hematogenous dissemination to develop skin lesions. This may explain the reasons for sparing the anogenital area (the most common site) and initial presentation mimicking acute tonsillitis. Cutaneous manifestations occur in 95% of patients with mpox.[1] The number of skin lesions ranges from a few to hundreds, which may increase over time.[1–3] In this patient, the number of skin lesions was scarce and the first lesion arose on the palm (the least common site), thus posing a diagnostic challenge to clinicians. Some diseases may present similar acrally distributed or widespread vesiculopustular eruptions and should be considered differential diagnoses. These include hand-foot-and-mouth disease, orf disease, pompholyx, palmoplantar pustulosis, HSV infection, varicella, syphilis, and nodular scabies.[2,3,5,7] The dermoscopic features of mpox have been previously reported, including diffuse bright white structureless area for vesiculopustular lesions and yellow-to-brown central umbilication/crust surrounded by bright whitish structureless halo for umbilicated pustules or crusted lesions.[4,5] In this patient, we propose that the distinctive dermoscopic “rising sun” sign for the pustules of mpox, characterized by a central homogeneous yellow area surrounded by a bright erythematous halo, is a potential diagnostic hallmark for mpox, as this pattern does not appear in other vesiculobullous disorders.[8] This case highlights that the initial clinical presentation of mpox may be atypical. The detection of centrifugal asynchronous skin lesions with lymphadenopathy and the characteristic dermoscopic “rising sun” sign for pustules may assist the diagnosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest Prof. Cheng-Che E. Lan and Prof. Stephen Chu-Sung Hu, editorial board members at Dermatologica Sinica, had no roles in the peer review process of or decision to publish this article. 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引用次数: 1

Abstract

Dear Editor, Mpox (formerly known as monkeypox), a zoonotic disease caused by the monkeypox virus, has caused recent global outbreaks.[1,2] The initial clinical presentation of mpox may manifest with nonspecific symptoms, which may result in delayed diagnosis. Herein, we report a case of mpox with an atypical clinical presentation and the “rising sun” sign observed on dermoscopy. A 44-year-old Taiwanese man, who has sex with men (MSM), presented with a 1-week history of fever, headache, sore throat, and left neck pain and a 4-day history of itchy rash on the limbs. His medical history includes human immunodeficiency virus (HIV) infection, which is being managed with emtricitabine/rilpivirine/tenofovir/alafenamide. He had recently received a diagnosis of acute tonsillitis at the otolaryngology clinic and was treated with amoxicillin/clavulanic acid. However, the symptoms did not improve, and a few vesiculopustular lesions developed on the distal parts of the limbs, starting from the left palm and progressing to the left forearm and legs. Physical examination showed exudative and swollen left tonsil, tender left cervical lymphadenopathy, and asynchronous skin lesions comprising crusted lesions on the left palm and forearm and pustules with perilesional erythema on the left hand and legs [Figure 1a-f]. Polarized dermoscopic examination revealed homogeneous brownish coloration for the left palm-crusted lesion, brown-to-red central crust with peripheral erythema for the left forearm-crusted lesion, and central homogeneous yellow area surrounded by bright erythematous halo (resembling “rising sun”) for pustules on the left hand and legs [Figure 2a-f]. The torso and anogenital region were spared.Figure 1: Clinical images. (a) Swollen left tonsil with whitish-yellow exudate was noted on examination of the oral cavity. (b and c) Crusted lesions on the left palm and forearm. (d-f) Pustules with perilesional erythema on the left hand, ankle, and bilateral knees.Figure 2: Polarized dermoscopic images. (a) Homogeneous brownish coloration for the left palm-crusted lesion. (b) Brown-to-red central crust with peripheral erythema for the left forearm-crusted lesion. (c-e) Central homogeneous yellow area surrounded by bright erythematous halo for pustules, resembling “rising sun,” on the left hand, ankle, and knee. (f) Homogeneous yellow coloration with a central crust and mild peripheral erythema for the pustule on the right knee.Travel and contact history revealed that the patient had not traveled abroad recently but had engaged in unprotected oral sex with another man 2 weeks before the onset of the symptoms. Laboratory analysis revealed leukocytosis (13610/ul), elevated C-reactive protein level (15.49 mg/L), and a normal CD4 cell count (1003 cells/mm3). The HIV viral load was undetectable. Serological tests for herpes simplex virus (HSV), varicella-zoster virus, and syphilis were negative. Due to suspicion of mpox based on clinical features and epidemiologic criteria, real-time polymerase chain reaction tests on viral swabs from the pharynx and vesiculopustular fluid were conducted. The results confirmed the diagnosis of mpox (the cycle threshold (Ct) values were 36 and 24, respectively). He was then admitted to a negative pressure isolation room, and supportive care was provided. No new-onset vesiculopustular lesions were seen thereafter. All skin lesions had become crusted 2 weeks after admission, and the patient was discharged. Mpox is characterized by a prodromal phase of fever, constitutional symptoms, and lymphadenopathy, followed by an eruptive phase of centrifugally evolving macules, papules, vesiculopustules, crusted lesions, or ulcers, which can present simultaneously or at different stages of evolution.[1–4] The most frequently affected cutaneous areas include the anogenital area, followed by the trunk/limbs, face, and palms/soles.[1,2] Mucosal lesions occurred in approximately 41% of patients, mostly presented in the anogenital area.[1] Oropharyngeal symptoms, such as oral or tonsillar lesions and pharyngitis, as presenting symptoms are uncommon, observed in only 5% of patients.[1] Mpox is mainly transmitted through sexual close contact with infected individuals, especially MSM.[1,2,5,6] In our patient, the prodromal symptoms of sore throat with left cervical lymphadenopathy may suggest that the virus enters oral epithelial cells through receptive oral sexual exposure and then replicates in the cervical lymph nodes with subsequent hematogenous dissemination to develop skin lesions. This may explain the reasons for sparing the anogenital area (the most common site) and initial presentation mimicking acute tonsillitis. Cutaneous manifestations occur in 95% of patients with mpox.[1] The number of skin lesions ranges from a few to hundreds, which may increase over time.[1–3] In this patient, the number of skin lesions was scarce and the first lesion arose on the palm (the least common site), thus posing a diagnostic challenge to clinicians. Some diseases may present similar acrally distributed or widespread vesiculopustular eruptions and should be considered differential diagnoses. These include hand-foot-and-mouth disease, orf disease, pompholyx, palmoplantar pustulosis, HSV infection, varicella, syphilis, and nodular scabies.[2,3,5,7] The dermoscopic features of mpox have been previously reported, including diffuse bright white structureless area for vesiculopustular lesions and yellow-to-brown central umbilication/crust surrounded by bright whitish structureless halo for umbilicated pustules or crusted lesions.[4,5] In this patient, we propose that the distinctive dermoscopic “rising sun” sign for the pustules of mpox, characterized by a central homogeneous yellow area surrounded by a bright erythematous halo, is a potential diagnostic hallmark for mpox, as this pattern does not appear in other vesiculobullous disorders.[8] This case highlights that the initial clinical presentation of mpox may be atypical. The detection of centrifugal asynchronous skin lesions with lymphadenopathy and the characteristic dermoscopic “rising sun” sign for pustules may assist the diagnosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest Prof. Cheng-Che E. Lan and Prof. Stephen Chu-Sung Hu, editorial board members at Dermatologica Sinica, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
猴痘具有不典型的临床表现和独特的皮肤镜检查结果
亲爱的编辑,猴痘(以前称为猴痘)是一种由猴痘病毒引起的人畜共患疾病,最近在全球暴发。[1,2] m痘的最初临床表现可能表现为非特异性症状,这可能导致诊断延迟。在此,我们报告一例m痘的不典型临床表现和“旭日”征观察皮肤镜。一名44岁台湾男男性行为者(MSM),表现为发热、头痛、喉咙痛、左颈部疼痛1周,四肢发痒皮疹4天。他的病史包括人类免疫缺陷病毒(HIV)感染,目前正在使用恩曲他滨/利匹韦林/替诺福韦/阿拉芬胺进行治疗。他最近在耳鼻喉科诊所被诊断为急性扁桃体炎,并接受阿莫西林/克拉维酸治疗。然而,症状没有改善,肢体远端出现少量囊泡性病变,从左手掌开始,进展到左前臂和腿部。体格检查显示左侧扁桃体渗出肿胀,左侧颈淋巴肿大,非同步皮肤病变,包括左手掌和前臂结痂,左手和腿部脓疱伴病灶周围红斑[图1a-f]。偏光皮肤镜检查显示,左手掌结痂呈均匀的褐色,左前臂结痂呈棕红色,周围有红斑,左手和腿部脓疱呈中心均匀黄色,周围有明亮的红斑晕(类似“旭日”)[图2a-f]。躯干和肛门生殖器区域没有受到伤害。图1:临床影像。(a)口腔检查发现左侧扁桃体肿胀伴黄白色渗出物。(b和c)左手掌和前臂的结痂病变。(d-f)左手、脚踝和双膝脓疱伴病灶周围红斑。图2:偏振皮肤镜图像。(a)左侧手掌结痂病变呈均匀的褐色。(b)左前臂有棕色到红色的中央结痂,周围有红斑。(c-e)左侧、踝关节和膝盖中心均匀的黄色区域,周围有明亮的红斑晕状脓疱,类似“旭日”。(f)右膝脓疱呈均匀黄色,中心有硬壳,周围有轻度红斑。旅行和接触史显示,患者最近没有出国旅行,但在出现症状前2周曾与另一名男子进行无保护的口交。实验室分析显示白细胞增多(13610/ul), c反应蛋白水平升高(15.49 mg/L), CD4细胞计数正常(1003个细胞/mm3)。HIV病毒载量检测不到。单纯疱疹病毒(HSV)、水痘带状疱疹病毒和梅毒的血清学试验均为阴性。根据临床特征和流行病学标准怀疑为m痘,对咽拭子和囊疱液进行实时聚合酶链反应试验。结果证实了m痘的诊断(循环阈值(Ct)分别为36和24)。随后,他被送入负压隔离室,并得到了支持性护理。术后未见新发水疱性病变。入院后2周,所有皮肤病变均结痂,出院。麻疹的特征为发热、体质症状和淋巴结病变的前体期,随后是离心发展的斑疹、丘疹、水疱、结痂性病变或溃疡的爆发期,可同时出现或在不同的发展阶段出现。[1-4]最常受影响的皮肤区域包括肛门生殖器区域,其次是躯干/四肢、面部和手掌/脚底。[1,2]约41%的患者发生粘膜病变,主要表现在肛门生殖器区域[1]。口咽症状,如口腔或扁桃体病变和咽炎,作为主要症状并不常见,仅在5%的患者中观察到。[1]麻疹主要通过与感染者密切性接触传播,尤其是男男性接触者。[1,2,5,6]在我们的患者中,伴有左侧颈部淋巴结病的喉咙痛的前体症状可能提示病毒通过接受性口交接触进入口腔上皮细胞,然后在颈部淋巴结复制,随后血液传播形成皮肤病变。这也许可以解释为什么保留肛门生殖器区域(最常见的部位)和最初的表现模仿急性扁桃体炎。95%的m痘患者出现皮肤表现。[1]皮肤损伤的数量从几个到几百个不等,随着时间的推移可能会增加。
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来源期刊
Dermatologica Sinica
Dermatologica Sinica DERMATOLOGY-
CiteScore
2.80
自引率
20.00%
发文量
28
审稿时长
>12 weeks
期刊介绍: Dermatologica Sinica aims to publish high quality scientific research in the field of dermatology, with the goal of promoting and disseminating dermatological-related medical science knowledge to improve global health. Articles on clinical, laboratory, educational, and social research in dermatology and other related fields that are of interest to the medical profession are eligible for consideration. Review articles, original articles, brief reports, case reports and correspondence are accepted.
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