In a recently published report in the Journal of Infection, scientists have presented the first documented case of coinfection with monkeypox virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and human immunodeficiency virus (HIV).
Monkeypox is a zoonotic virus belonging to the Orthopoxvirus genus in the family Poxviridae. The virus is primarily endemic to the tropical rainforest areas of central and west Africa. Recently, severe outbreaks of monkeypox infection have been detected in non-endemic countries worldwide.
Since January 2022, over 16,000 cases of monkeypox infection have been detected in over 74 countries. Considering these sudden outbreaks, the World Health Organization (WHO) has declared monkeypox a public health emergency.
Human-to-human virus transmission primarily occurs through close contact with infectious skin lesions, fomites, seminal fluids, and oropharyngeal secretions. Most recent cases have been detected in men who have sex with other men. A relatively higher prevalence of monkeypox and HIV coinfections has also been noticed.
The coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 is still ongoing with considerable morbidities and mortalities worldwide. Monkeypox and SARS-CoV-2 infections share various similar symptoms, including fever, headache, fatigue, and swelling of lymph nodes. The coexistence of these pathogens in nature increases the risk of coinfection, which can subsequently put more burden on the global healthcare system.
Monkeypox, SARS-CoV-2, and HIV coinfection
The case report described in the article is about a 36-year-old Italian man who spent five days in Spain in June 2022. He had unprotected sex with men during the stay. Nine days after his return, he developed fever, sore throat, headache, fatigue, and lymph node enlargement. He tested positive for SARS-CoV-2 infection.
Afterward, he developed severe skin rashes on the face and other body parts, followed by the formation of pustules. Given the severity of the condition, he visited the hospital's emergency department, where he was subsequently referred to the infectious disease unit for admission.
In the hospital medical report, He mentioned having syphilis in 2019. In 2021, he was tested for HIV infection, but the report was negative. He also mentioned being treated with carbamazepine because of bipolar disorder. He was diagnosed with COVID-19 in January 2022. Regarding vaccination, he reported receiving two doses of mRNA COVID-19 vaccine (Pfizer) in December 2021.
Physical examination revealed spots and skin lesions in various body parts, including the perianal region. A modest enlargement of the liver and spleen and painful enlargement of the lymph nodes were noticed.
Biochemical examination revealed increased C-reactive protein (CRP) and fibrinogen levels and high prothrombin time. Chest X-ray revealed a parenchymal hypodiaphany.
Biological specimens were collected from his skin lesions and respiratory tract and subjected to reverse transcription-polymerase chain reaction (RT-PCR). The report confirmed the presence of monkeypox infection. He also tested positive for HIV. Sequencing of the SARS-CoV-2 genome confirmed that he was infected with the omicron sub-variant BA.5.1.
He was treated with 500 mg of sotrovimab intravenously. On day five post-admission, almost all symptoms were resolved, although he remained positive for SARS-CoV-2 and monkeypox virus. However, he was discharged from the hospital and advised to isolate himself at home.
After eight days post-discharge, he visited the hospital to take a new test for monkeypox infection, which yielded a virus-positive result. The treatment for his HIV infection was initiated with a triple combination of dolutegravir, abacavir, and lamivudine.
This case report describes the presence of monkeypox, SARS-CoV-2, and HIV coinfection in an adult man who had unprotected sex with men. Considering the case findings, scientists suggest that patients with flu-like symptoms as well as a recent travel history to monkeypox outbreak regions should be examined for both SARS-CoV-2 and monkeypox even if they do not present with skin lesions/rashes.
Furthermore, the case report highlights that monkeypox infection could predominantly spread between humans through sexual transmission. This highlights the need for a thorough screening of sexually transmitted infections in patients with monkeypox infection.
A long-term presence of monkeypox virus in oropharyngeal swab indicates that the patient may remain contagious even after the resolution of symptoms.