In the setting of the current monkeypox outbreak it is important to consider different clinical courses. This includes skin changes/lesions that are primarily localized at the presumed inoculation sites, a low exanthematous component, and onset of general symptoms only over the course if the illness.
Ricardo Niklas Werner and colleagues present the case of a 30-year old man with painful, itchy skin lesions localized mainly in the genital region, which had been present for ten days. Examination revealed skin-colored, centrally indented, partly ulcerated, fibrin-covered papules and hemorrhagic crusts up to 1cm in diameter on the penis, scrotum, and lower abdomen, and to a lesser extent elsewhere, as well as inguinal lymphadenopathy. Because of the patient's history of multiple male sex partners, Werner et al. suspected monkeypox despite the limited spatial extent of the rash and the delayed onset of general symptoms. PCR analysis of a lesional swab confirmed the diagnosis of the West African variant of monkeypox.
Werner, R.N., et al. (2022) Monkeypox: a localized rash followed by general symptoms. Deutsches Ärzteblatt International. doi.org/10.3238/arztebl.m2022.0250.