LAUSR

Dear Editor, A 44-year-old male presented to the emergency department with high-grade fever (39 C), penile edema and genital rash. He reported the onset of a painless genital rash 5 days earlier. The patient was sexually active with female partners. Fifteen days earlier, following his return from Tunisia to France, he had unprotected insertive anal intercourse with a new partner. The patient did not report any cutaneous or genital rash of his new partner. There was no dysuria or urethral discharge. His physical examination revealed three pruritic, non-tender, ulcerated lesions of 3mm on the shaft of the penis and the suprapubic area. In addition, a well-demarcated red plaque at the suprapubic regions, penile and scrotal skin with raised border (Figure 1a and b). There was no rash on other areas of his body. Urine analysis and culture were negative. Laboratory tests were normal except for a high CRP of 121. Tests for syphilis, chlamydia, gonorrhea, HIV, HBV, HCV, HSV and VZV were all negative. Polymerase-chain-reaction assays collected from two different ulcers were positive for monkeypox. The working diagnosis was genital monkeypox associated with adjacent erysipelas. The patient was started on antibiotics (Clindamycin and Amoxicillin/Clavulanic acid) and fluids. Over the next 48 hours, the penile swelling decreased but new vesicular lesions appeared on his left arm (Figure 1c). On day 5 of admission, the patient was afebrile. He was discharged on day 6. By day 14 the penile swelling has largely resolved and the genital lesions were crusted over. A rapidly emerging outbreak of monkeypox infection in over 20 countries in Europe, North and South America and the Middle East commenced in May 2022 [1]. The transmission of the monkeypox virus can occur via respiratory secretions, such as respiratory droplets, or through direct contact with mucocutaneous lesions. The virus can also be transmitted through direct contact with body fluids during sexual relations [2]. The current outbreak of monkeypox infections has specific characteristics: it occurs in the men who have sex with men community; known contact is mostly sexual [3]. Patrocinio-Jesus and Perizzu [4] reported the first case of genital monkeypox in Europe. It was the case of a 31-yearold man with a well-controlled infection with the human immunodeficiency virus who presented with painless genital rash 3weeks after condomless intercourse with a new male partner. Two weeks after his presentation, the patient’s lesions had abated without specific intervention. Despite genital lesions not being common in monkeypox, the diagnosis might be considered by every urologist during the ongoing monkeypox outbreak. This may help in the timely management of the patient. To our knowledge, this is the second case of reported genital monkeypox in Europe.