Sex: M
Vaccine: UNK
Symptoms: Tenderness, Treponema test negative, White blood cell count increased
Clinical narrative: Monkeypox; Severe anorectal proctitis; Facial rash worsened; Facial rash worsened; Literature citations:  Case reference number US-BN-2023-000314 is a literature case report, titled as stated above, identified on 21-Feb-2023 and concerns a 41-year-old male patient.  The patient was presented to the emergency department (ED) with rectal pain and facial rash. The patient's past medical history was notable for human immunodeficiency virus (HIV) with recent non-compliance with anti-retroviral therapy. The patient reported visiting an outpatient clinic earlier in the week and was told facial rash was unlikely to be secondary to monkeypox and received a monkeypox vaccination (brand name: unknown, batch number: unknown), at an unknown dose, route, or site of administration. The facial rash worsened over the following days and the patient developed severe rectal pain with bowel movements and mild dysuria, prompting the ED visit. Physical exam was notable for multiple clustered, umbilicated lesions on the face, groin, penis, and peri-anal region. Vital signs were within normal limits. Leukocyte count was 9.7 k/µL (normal range: 4.810.8 k/µL). CD4 count was 48/mm3. Monkeypox PCR from a penile lesion swab was sent, subsequently positive. Gonorrhea and chlamydia DNA tests were negative. Rapid plasma reagin was performed to evaluate for syphilis and was found to be negative. The patient was discharged from the ED with pain medication (brand name: unknown) and stool softeners (brand name: unknown).   On an unspecified date, reported two days later, the patient returned to the ED with persistent abdominal pain, liquid bowel movements, a small amount of red blood after wiping, and increasing skin lesions. On clinical exam the patient was febrile with a temperature of 101 F and digital rectal examination was significant for exquisite tenderness but without frank blood. Leukocyte count was slightly elevated at 10.9 k/µL. Contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis revealed severe anorectal proctitis with discrete large mural hypoattenuated anorectal ulcers, perirectal fat stranding, and pelvic free fluid. Additional findings included an increased number of small inguinal lymph nodes and a small right pleural effusion. There was no abscess, peri-anal fistula, or extra-luminal air.  On an unspecified date, Infectious Disease was consulted, and the patient was admitted to the hospital and started on broad-spectrum antibiotics (brand name: unknown) and tecovirimat (brand name: unknown). General surgery and interventional radiology were also consulted for possible abscess drainage that was deferred secondary to lack of organized collection. The patient clinically improved with conservative management.   This case highlights that monkeypox could present clinically with severe proctitis and had distinctive imaging findings on CT scan not typically seen in other causes of proctitis. Severe circumferential anorectal mural thickening with broad discrete non-enhancing hypoattenuated zones due to intramural ulcers on CT scan in young men with associated rash and sexual history should invoke consideration for monkeypox infection and could be suggested by the radiologist. Additional findings of severe anorectal proctitis were also seen in this patient, including perirectal fat infiltration, presacral edema, ascites, and an increased number of small inguinal lymph nodes. The imaging differential diagnosis includes other causes of infectious proctitis, namely gonorrhea, syphilis, herpes simplex virus (HSV), and cytomegalovirus (CMV), as well as radiation-induced proctitis, ischemic proctitis, and neoplasm. Radiologic literature on this topic was scarce due to the recent onset of the monkeypox pandemic.    Reported magnetic resonance imaging (MRI) descriptions included rectal wall thickening, rectal wall perforation, enlarged mesorectal space lymph nodes, and inflammatory change of the lower anal canal mucosa representing peri-anal ulcers. Reported CT descriptions included sigmoid, rectal, and anal wall thickening, infiltrated peri-rectal fat, and enlarged peri-rectal and iliac chain lymph nodes. Reported proctoscopic features included severe proctitis with or without anal or rectal ulcers. The primary presenting symptoms in this case were painful defecation and rectal pain, though symptoms of proctitis in the monkeypox population had also included rectal bleeding, fecal urgency, tenesmus, and abdominal pain.  On an unspecified date, reported as 11 days after admission, a repeat CT scan, imaging findings revealed improvement in anorectal mural thickening and ulcers with decrease in perirectal fat stranding, and resolution of pelvic ascites, after the patient was treated with tecovirimat (brand name: unknown) and antibiotics (brand name: unknown), given to treat potential secondary bacterial abscess.  The patient was discharged home to complete a 14-day course of tecovirimat (brand name: unknown) and one additional week of oral antibiotics (brand name: unknown).  At the time of the initial report, the outcome of the events of monkeypox, anorectal proctitis, facial rash, and condition worsened was unknown.   The reporter did not provide the seriousness and causality assessment of the events of monkeypox, anorectal proctitis, facial rash, and condition worsened. Additionally, the events of monkeypox and proctitis were assessed as serious, due to medically significant criteria.  No further information was provided.; Reporter's Comments: A 41-year-old male patient received monkeypox vaccine at an unknown dose, route, or site of administration. The patient reported visiting an outpatient clinic earlier in the week and was told facial rash was unlikely to be secondary to monkeypox, but the facial rash worsened over the following days. Patient also developed severe rectal pain with bowel movements and mild dysuria and later on was diagnosed with severe proctitis and monkeypox. Proctitis and monkeypox are unlisted for MVA-BN according to CCDS version 1 and PI, whilst aggravated facial rash is listed per CCDS and unlisted per PI. The patient's past medical history was notable for human immunodeficiency virus (HIV) with recent non-compliance with anti-retroviral therapy. Patient's impaired immune system due to HIV is a significant confounding factor for developing monkeypox. Having this in mind the causality for monkeypox is assessed as not related to MVA-BN. The authors stated that cases of monkeypox can present with severe proctitis. Having this in mind, as well as the pathophysiology of reported proctitis, it is highly unlikely that MVA-BN can contribute in development of this event, therefore the causality is assessed as not related to suspect product. Even though patient had facial rash before the vaccination, after the vaccine his rash aggravated and due to temporal relationship and product known safety profile, at least a contributory role of MVA-BN in aggravating this facial rash cannot be excluded with certainty. Therefore the causality for aggravated facial rash is assessed conservatively as related to MVA-BN. The case is serious due to medical significance of monkeypox and severe proctitis.; Sender's Comments: A 41-year-old male patient received monkeypox vaccine at an unknown dose, route, or site of administration. The patient reported visiting an outpatient clinic earlier in the week and was told facial rash was unlikely to be secondary to monkeypox, but the facial rash worsened over the following days. Patient also developed severe rectal pain with bowel movements and mild dysuria and later on was diagnosed with severe proctitis and monkeypox. Proctitis and monkeypox are unlisted for MVA-BN according to CCDS version 1 and PI, whilst aggravated facial rash is listed per CCDS and unlisted per PI. The patient's past medical history was notable for human immunodeficiency virus (HIV) with recent non-compliance with anti-retroviral therapy. Patient's impaired immune system due to HIV is a significant confounding factor for developing monkeypox. Having this in mind the causality for monkeypox is assessed as not related to MVA-BN. The authors stated that cases of monkeypox can present with severe proctitis. Having this in mind, as well as the pathophysiology of reported proctitis, it is highly unlikely that MVA-BN can contribute in development of this event, therefore the causality is assessed as not related to suspect product. Even though patient had facial rash before the vaccination, after the vaccine his rash aggravated and due to temporal relationship and product known safety profile, at least a contributory role of MVA-BN in aggravating this facial rash cannot be excluded with certainty. Therefore the causality for aggravated facial rash is assessed conservatively as related to MVA-BN. The case is serious due to medical significance of monkeypox and severe proctitis.