Sex: M
Vaccine: SMALLMNK
Symptoms: Lymphangitis, Metabolic function test normal, Monkeypox, Nodule, Pain in extremity
Clinical narrative: Monkeypox; Secondary lymphangitis; Literature citation:  Case reference number US-BN-2022-004218 is a literature case report, title as stated above, identified on 25-Oct-2022 and concerns a male patient of an unknown age, reported as in his mid 30s.  The aim of this study was to elaborate the first known case of a patient with monkeypox presentation after being vaccinated with the first dose of Jynneos vaccine (batch number not provided). The initial presentation was of acute bacterial paronychia. This incident suggests the need for individuals at high-risk for monkeypox infection with altered immunity to receive two vaccination doses.  A male in his mid-30s with ulcerative colitis, regularly treated with adalimumab 40 mg (brand name unknown) every other week for the last 6 years, presented to his primary physician with a 4-day history of periungual erythema and pain on his left thumb. A prodromal tingling sensation preceded the erythema two days earlier while he had been travelling. He denied other systemic symptoms including fever or chills. Ten days prior to the initial tingling symptom, the patient received his first Jynneos vaccine. During his trip and six days post-vaccination, the patient had unprotected sexual intercourse with different male partners while he was taking continuous pre-exposure prophylaxis (PrEP) for human immunodeficiency viruses (HIV). He denied any sexual activity 15 days prior to the vaccine administration. On physical examination, a left periungual fluctuated red nodule with an enlarged epitrochlear lymph node was observed as well as an erythematous lymphatic streak on his left forearm. No other cutaneous finding or systemic symptoms were noted. The diagnosis of acute bacterial paronychia was initially made clinically, and the patient was referred to the emergency department (ED) for surgical drainage and blood work. During his visit in the ED, complete blood count and basic metabolic panel were within normal limits, including C-reactive protein (CRP). The paronychia was drained, and the patient received a single dose of intravenous ceftriaxone 2 g (brand name unknown) and was discharged with a treatment of cephalexin 2 g (brand name unknown) per day for a week. A week later during the patient's follow-up visit to the clinic, a new set of discrete vesiculo-pustules on his left thumb, left hand and right elbow were noted. A real-time PCR test was performed using DNA extracted from pharyngeal lesions which were diagnostic for monkeypox virus (MPXV). Bacterial smear and culture were negative. The patient was diagnosed with monkeypox infection and secondary lymphangitis. The lesions resolved spontaneously after three weeks with residual atrophic scars.  Due to fear of MPXV infection, the patient refrained from any sexual contact for at least 15 days prior to his vaccination.   It was concluded that since the onset of his first symptom exceeded 25 days from his last sexual contact pre-vaccination and only 5 days from his first sexual contact postvaccination, it was more plausible that the monkeypox infection occurred during the latter. Moreover, the fact that patient received only a single dose of the vaccine and that he was partially immunocompromised due to prolonged treatment with a tumor necrosis factor (TNF)-alpha antagonist may also strengthen the presumption that he developed symptoms more rapidly. Monkeypox virus infection might have atypical manifestations or more severe illness  in immunocompromised people that might complicate diagnosis. In the current outbreak HIV infection was present in 28-51% of MPXV-infected Gay, Bisexual, and other Men who have Sex with Men (GBMSM) with known HIV status. First, a single Jynneos vaccine may not be sufficient for vaccination against the current MPXV strain, especially with altered immunocompetent or immunocompromised patients. Such patients may necessitate both vaccine doses, as recommended by the manufacturer, who also mentions that full immunity is granted 2 weeks after the second dose. Second, it is not yet known how long after a single vaccination dose one becomes immunized, especially in those with altered immune status. A third potential immunologic explanation in this case is that TNF cytokines are important modulators of viral replication and host response to infections.   Non-significant case correction performed for information received from Bavarian Nordic on 27-Oct-2022 to include local BN case ID number.; Reporter's Comments: An adult male patient (aged in range 30-39) was vaccinated with the first dose of Jynneos, applied via unknown route of administration. Ten days later, the the patient experienced pain in his left thumb and periungual tickling and erythema. Upon examination, a left periungual fluctuated red nodule with an enlarged epitrochlear lymph node was observed, as well as an erythematous lymphatic streak on the left forearm. Initial diagnosis was acute bacterial paronychia. CBC and CRP were within normal limits. A single dose of Ceftriaxone was administered, followed by an ambulatory treatment with Cephalexine. A week later, the patient developed vesico-pustulous lesions on his left thumb, left hand and right elbow, as well as pharyngeal lesions. PCR test of pharyngeal lesions revealed Monkeypox virus. Bacterial smear and culture were negative. Diagnosis was monkeypox infection and secondary lymphangitis. Three weeks later, the lesions resolved spontaneously with residual atrophic scars. Monkeypox and lymphangitis are unlisted per the agency 1 and agency 2 for Jynneos. Medical history included ulcerative colitis and partially immunocompromised. Concomitant medications included Adalimumab, pre-exposure HIV prophylaxis, TNF-alpha antagonist. Considering that the patient was immunocompromised, and had not completed the entire course of Jynneos (had only received one dose at the time of onset), the event of monkeypox is assessed as not related to Jynneos. The event of secondary lymphangitis is assessed as not related to the vaccination, but as secondary to the monkeypox infection. The case is serious due to medical significance of both events.; Sender's Comments: An adult male patient (aged in range 30-39) was vaccinated with the first dose of Jynneos, applied via unknown route of administration. Ten days later, the patient experienced pain in his left thumb and periungual tickling and erythema. Upon examination, a left periungual fluctuating red nodule with an enlarged epitrochlear lymph node was observed, as well as an erythematous lymphatic streak on the left forearm. Initial diagnosis was acute bacterial paronychia. CBC and CRP were within normal limits. A single dose of Ceftriaxone was administered, followed by an ambulatory treatment with Cephalexine. A week later, the patient developed vesico-pustulous lesions on his left thumb, left hand and right elbow, as well as pharyngeal lesions. PCR test of pharyngeal lesions revealed Monkeypox virus. Bacterial smear and culture were negative. Diagnosis was monkeypox infection and secondary lymphangitis. Three weeks later, the lesions resolved spontaneously with residual atrophic scars. Monkeypox and lymphangitis are unlisted per the agency 1 and agency 2 for Jynneos. Medical history included ulcerative colitis and partially immunocompromised. Concomitant medications included Adalimumab, pre-exposure HIV prophylaxis, TNF-alpha antagonist. Considering that the patient was immunocompromised and had not completed the entire course of Jynneos (had only received one dose at the time of onset), the event of monkeypox is assessed as not related to Jynneos. The event of secondary lymphangitis is assessed as not related to the vaccination, but as secondary to the monkeypox infection. The case is serious due to medical significance of both events.