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Annals of Internal Medicine

Letters18 August 2022Monkeypox Virus–Associated Severe Proctitis Treated With Oral Tecovirimat: A Report of Two CasesFREEJose Lucar, MD, Afsoon Roberts, MD, Karl M. Saardi, MD, Rebecca Yee, PhD, Marc O. Siegel, MD, and Tara N. Palmore, MDJose Lucar, MDDivision of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC (J.L., A.R., M.O.S., T.N.P.), Afsoon Roberts, MDDivision of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC (J.L., A.R., M.O.S., T.N.P.), Karl M. Saardi, MDDepartment of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC (K.M.S.), Rebecca Yee, PhDDepartment of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC (R.Y.), Marc O. Siegel, MDDivision of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC (J.L., A.R., M.O.S., T.N.P.), and Tara N. Palmore, MDDivision of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC (J.L., A.R., M.O.S., T.N.P.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L22-0300 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Monkeypox is a viral zoonosis that is endemic in Central and Western Africa. An epidemic of monkeypox involving multiple nonendemic countries was identified in May 2022 (1). The illness includes systemic symptoms and skin eruptions, and more recent cases have involved proctitis with perianal lesions, some with severe anorectal pain (2, 3).Objective: To describe monkeypox and its treatment in 2 patients in the District of Columbia.Case Report: Patient 1 was a 26-year-old man receiving HIV preexposure prophylaxis who developed rectal pain and clear discharge 6 days after last receptive anal intercourse. A recent anonymous male partner was from Europe. Over the following days, he developed fever up to 38.7 °C, painful bilateral inguinal lymphadenopathy, and bilateral eye pain and redness. On the fourth day of illness, he defervesced but noted new pruritic, painful lesions in his mouth, face, and perianal area with severe rectal pain. Examination found a lower-lip ulcer and multiple pustules scattered on the right forehead, right soft palate, left flank, right upper back, and perianal area, with a 3-cm ring of erythema around the anal verge (Figure 1). Results of eye examination were normal. Testing was negative for HIV, syphilis, Neisseria gonorrhoeae, and Chlamydia trachomatis. All 3 lesions sampled were positive for orthopoxvirus DNA via polymerase chain reaction testing the next day. The patient was discharged with supportive care.Figure 1. Patient 1: ulcerative lesion in the internal aspect of the inferior lip, which was positive for orthopoxvirus DNA via polymerase chain reaction. Download figure Download PowerPoint Over the following 72 hours, the patient's rectal pain required opioids and he developed new skin lesions on his trunk and left arm. On the ninth day of symptoms, he began treatment with oral tecovirimat, 600 mg twice daily. His pain improved within the following 36 hours, and no new skin lesions formed. He reported no adverse effects. His rectal symptoms and skin lesions resolved by day 7 of the 14-day course of therapy.Patient 2 was a 37-year-old man receiving HIV preexposure prophylaxis who developed rectal bleeding, fever up to 39.3 °C, and fatigue 11 days after receptive anal intercourse with a man who was later diagnosed with monkeypox. Testing was negative for HIV, syphilis, N gonorrhoeae, and C trachomatis. Fever and fatigue lasted 1 day. On the third day of symptoms, he developed painful, pruritic, pustular skin lesions in his perianal area and scattered throughout his limbs and trunk. Examination found scattered pustular lesions, including 1 at an insect bite site on the right wrist and another at an abrasion on the right forearm (Figure 2). All 3 lesions sampled were positive for orthopoxvirus DNA via polymerase chain reaction testing 2 days later.Figure 2. Patient 2: pustular lesion in the site of a previous abrasion in the right forearm, which was positive for orthopoxvirus DNA via polymerase chain reaction. Download figure Download PowerPoint On the ninth day of illness, the patient developed severe rectal pain requiring opioids. He continued to develop new skin lesions on his trunk and limbs. The next day, he began treatment with oral tecovirimat, 600 mg twice daily. His pain improved within 48 hours, and no new skin lesions formed. He reported mild, transient fatigue after starting tecovirimat treatment. His rectal symptoms had almost resolved by day 4 of therapy.Discussion: As of 17 August 2022, the District of Columbia had reported 350 cases of monkeypox confirmed by polymerase chain reaction—the highest rate of cases per capita in the United States (4). Of those case patients, 69% were between 25 and 39 years old and 98% identified as male, 48% as White, and 37% as Black. Most patients have had a mild, self-limiting clinical course of disease, but some have had severe, localized manifestations, including proctitis (2, 3).There is no approved antiviral for monkeypox, and optimal management has not been established. However, antiviral agents approved for use against smallpox are expected to have activity against monkeypox. These include tecovirimat, cidofovir, and brincidofovir (5). Tecovirimat is a potent inhibitor of the VP37 orthopoxvirus protein, which mediates the formation and egress of enveloped virions. It is available from the Strategic National Stockpile (5). Current guidance from the Centers for Disease Control and Prevention recommends considering treatment in patients with severe monkeypox disease and those at risk for progression to severe disease.Both patients with severe monkeypox proctitis described in this report had rapid alleviation of rectal pain after starting treatment with oral tecovirimat, which was well tolerated. Clinicians should be aware of common adverse effects seen in previous studies, including headache and nausea (6). Although the direct effect of tecovirimat in precipitating the rapid alleviation of these patients' symptoms cannot be determined, we believe that early use of tecovirimat should be considered for patients with monkeypox and severe proctitis until randomized controlled trials of tecovirimat can be done.References1. World Health Organization. Multi-country monkeypox outbreak: situation update. 27 June 2022. Accessed at www.who.int/emergencies/disease-outbreak-news/item/2022-DON396 on 5 July 2022. Google Scholar2. Basgoz N, Brown CM, Smole SC, et al. Case 24-2022: a 31-year-old man with perianal and penile ulcers, rectal pain, and rash. N Engl J Med. 2022;387:547-556. [PMID: 35704401] doi:10.1056/NEJMcpc2201244 CrossrefMedlineGoogle Scholar3. de Nicolas-Ruanes B, Vivancos MJ, Azcarraga-Llobet C, et al. Monkeypox virus case with maculopapular exanthem and proctitis during the Spanish outbreak in 2022 [Letter]. J Eur Acad Dermatol Venereol. 2022;36:e658-e660. [PMID: 35675097] doi:10.1111/jdv.18300 CrossrefMedlineGoogle Scholar4. District of Columbia Department of Health. 2022 monkeypox outbreak data. 16 August 2022. Accessed at https://dchealth.dc.gov/node/1611066 on 17 August 2022. Google Scholar5. Centers for Disease Control and Prevention. Guidance for tecovirimat use under expanded access investigational new drug protocol during 2022 U.S. monkeypox cases. 10 June 2022. Accessed at www.cdc.gov/poxvirus/monkeypox/clinicians/Tecovirimat.html on 5 July 2022. Google Scholar6. Chinsangaram J, Honeychurch KM, Tyavanagimatt SR, et al. Safety and pharmacokinetics of the anti-orthopoxvirus compound ST-246 following a single daily oral dose for 14 days in human volunteers. Antimicrob Agents Chemother. 2012;56:4900-5. [PMID: 22777041] doi:10.1128/AAC.00904-12 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Division of Infectious Diseases, George Washington University School of Medicine and Health Sciences, Washington, DC (J.L., A.R., M.O.S., T.N.P.)Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC (K.M.S.)Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC (R.Y.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L22-0300.Corresponding Author: Tara N. Palmore, 2150 Pennsylvania Avenue NW, Washington, DC 20037; e-mail, [email protected]gwu.edu.This article was published at Annals.org on 18 August 2022. 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Monkeypox Virus–Associated Severe Proctitis Treated With Oral Tecovirimat: A Report of Two Cases