Sex: M
Vaccine: SMALLMNK
Symptoms: Monkeypox, Muscular weakness, Orthopoxvirus test positive, Patient isolation, Purpura
Clinical narrative: Monkeypox reinfection; Disseminated herpes zoster; Varriela zoster virus radiculopathy; Literature citation.  Case reference number US-BN-2024-000185 is a spontaneous literature case report, title as stated above, identified on 14-Feb-2024, and concerns a 38-year-old male patient.  The aim of the article was to present the importance of maintaining a high index of suspicion for monkeypox despite prior infection and vaccination, as suboptimal immune response could be possible in immunocompromised patients, and also noting the potential for co-infection necessitating timely diagnosis and appropriate testing.  A 38-years old man with human immunodeficiency virus (HIV history), at the time not on antiretroviral therapy, presented emergency department afebrile with five-day history of left knee pain and innumerable vesicular skin lesions and with vital signs significant only for tachycardia (110 beats per minute). The patient's history included prior genital monkeypox infection with penile lesions confirmed by positive real-time quantitative polymerase chain reaction (PCR) targeting the E9L DNA polymerase gene of monkeypox virus. As reported, the patient received a varicella vaccine as a child. The patient was discharged with a 14-days course of oral tecovirimat. The patient also received two doses of Jynneos (batch number unknown), at an unknown dose, route or site of administration, for unknown indication, two months after treatment and complete resolution of lesions.   On unspecified date, as reported eight months after the initial monkeypox infection, the patient presented to the emergency department. Physical examination revealed vesicular lesions on left leg, abdomen, chest, face, and scalp without a specific dermatomal distribution. Laboratory diagnostics showed HIV viral load of 101,00 copies/mL and absolute CD4 count of 74 cells/ mm3 with CD4 percentage of 10 percent. Disseminated herpes zoster was suspected and the patient was placed on airborne isolation precautions. Intravenous acyclovir 10 mg/kg every eight hours was initiated regarding positive varicella zoster virus polymerase chain reaction (PCR) lesion swab. Treponemal antibody testing was positive and rapid plasma regain (RPR) was non-reactive, representing known prior history of treated syphilis, which was confirmed with the local health department. Herpes simplex virus (HSV) and monkeypox PCR swabs of lower extremity lesions were negative. Monkeypox swabs were obtained according to CDC guidance of two swabs from the same lesion on the lower extremity which both returned negative. Shortly after acyclovir infusion the patient developed fevers up to 102.4 Faradays. Repeat monkeypox PCR was obtained from a different lesion on patient's leg than from where initial swabs were collected regarding significant immunosuppression and prior history of monkeypox and returned positive. The patient was started on treatment with oral tecovirimat 600 mg every 12 hours. The patient's rash had paradoxical worsening with haemorrhagic conversion then slowly improved. Hospital stay was complicated left lower extremity weakness and low back pain which was attributed to VZV radiculopathy. The patient started treatment with oral methylprednisolone per neurology recommendations which led to improving of symptoms. Prior to patient's discharge, healing of lesions was noted with no formation of new lesion and resolution of fevers.   On unspecified date, the patient was restarted on antiretroviral therapy and discharged home on oral valacyclovir 1g three times daily to complete a 21-day course for disseminated herpes zoster and 14- day course of tecovirimat.  At the time of the initial report, the patient was recovering from the events of monkeypox and herpes zoster disseminated, while the outcome for the event of radiculopathy was unknown.  The reporter assessed the events of monkeypox, herpes zoster disseminated and radiculopathy as serious due to criteria of hospitalization. Additionally, the events of monkeypox, herpes zoster disseminated, and radiculopathy were assessed as serious due to the criteria of medical significance. The reporter assessed the events of monkeypox, herpes zoster disseminated and radiculopathy as not related to Jynneos, reported as that given that the patient had complete resolution of prior penile monkeypox lesion and the appearance of new lesions in an unrelated area, it was suspected the patient had a new infection and not a prolonged infectios course and all in the setting of reactivation of varicella zoster virus manifesting as disseminated disease. Additionally, it was reported that it was possible that cutaneous lesions from one infection served as an entry point for the other and that the patients depressed immune system increased the risk of dissemination and severe disease.  No further information was provided.; Reporter's Comments: A 38-year-old male patient experienced serious events of herpes zoster disseminated, monkeypox and herpetic radiculopathy (hospitalization and medical significance) an unknown amount of time after the patient received two doses of Jynneos for unknown indication. All the events are unlisted and unexpected for Jynneos according to the insert. The patient current condition included human immunodeficiency virus and the patient was immunocompromised. The outcome was unknown. Considering that the vaccine is non-replicating and does not contain monkeypox virus, monkeypox has been assessed as not related to Jynneos. Also, the remaining two events have been considered as not related to Jynneos, considering the nature of the events. This case is considered as serious due to hospitalization and medical significance.; Sender's Comments: A 38-year-old male patient experienced serious events of herpes zoster disseminated, monkeypox and herpetic radiculopathy (hospitalization and medical significance) an unknown amount of time after the patient received two doses of Jynneos for unknown indication. All the events are unlisted and unexpected for Jynneos according to the insert. The patient current condition included human immunodeficiency virus and the patient was immunocompromised. The outcome was unknown. Considering that the vaccine is non-replicating and does not contain monkeypox virus, monkeypox has been assessed as not related to Jynneos. Also, the remaining two events have been considered as not related to Jynneos, considering the nature of the events. This case is considered as serious due to hospitalization and medical significance.