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CORRESPONDENCE Table of Contents  
Ahead of print publication
Breakthrough monkeypox infection in a Taiwanese male with human immunodeficiency virus 6 days after vaccination


1 Department of Dermatology, Taipei City Hospital, Taipei, Taiwan
2 Department of Internal Medicine, Taipei City Hospital, Taipei, Taiwan
3 Department of Dermatology, Taipei City Hospital; Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan

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Date of Submission25-Aug-2022
Date of Decision25-Oct-2022
Date of Acceptance15-Nov-2022
Date of Web Publication20-Feb-2023
 


How to cite this URL:
Chao YC, Hu BS, Liu C, Lee MS. Breakthrough monkeypox infection in a Taiwanese male with human immunodeficiency virus 6 days after vaccination. Dermatol Sin [Epub ahead of print] [cited 2023 Mar 27]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=370023




Dear Editor,

The global outbreak of monkeypox started in Europe in May 2022 and rapidly spread to more than 80 countries worldwide. In the current outbreak, affected patients have usually had no travel history to endemic areas in Africa, and transmission has mainly occurred through close contact with infected humans, especially men who have sex with men. The vesiculopustular and maculopapular skin rash mostly develops in the anogenital area.[1] Herein, we report the case of a patient who was diagnosed with breakthrough monkeypox infection in Taiwan after receiving vaccination in and returning from the United States.

A 29-year-old Taiwanese male had underlying syphilis, mood disorders, and human immunodeficiency virus (HIV) infection and was undergoing regular antiretroviral therapy (ART). He traveled to California in July 2022 and arrived back in Taiwan on August 2, 2022. He presented with lower back pain 2 days before his arrival, followed by one episode of fever of approximately 37.8°C–38°C, submandibular lymphadenopathy, and one asymptomatic pimple located on the chin within 3 days. He denied chills, headache, cough, diarrhea, or other associated symptoms. The patient had sexual intercourse with males in California, but he did not know whether his sexual partners had monkeypox. He had also received the monkeypox vaccination in San Francisco 6 days before the onset of lower back pain.

On physical examination, there was one firm skin-colored papule with a central crust located below the lower lip [Figure 1]a. A tiny papule with scanty scales was observed on the left mandible, accompanied by swollen and tender lymph nodes in the bilateral submandibular areas [Figure 1]b. Laboratory investigations revealed normal blood cell counts, bilirubin levels, and liver and kidney function. The CD4 cell count was 665 cells/mm3, and the HIV viral load was undetectable.
Figure 1: (a) One well-defined, firm skin-colored papule with a central crust was located, measuring 5 mm in diameter, below the lower lip; (b) swollen and tender lymph nodes were present in the bilateral submandibular areas.

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A further survey was conducted owing to the patient's underlying sexually transmitted diseases, travel history, and probable contact history. A polymerase chain reaction assay was collected from the exudate/crust of the papule below the lower lip, and the monkeypox virus infection was confirmed by the Taiwan Centers for Disease Control (CDC). During admission, the papule below the lower lip became purulent [Figure 2]a, and three new tiny papules developed on the mandible, right forearm, and left hand [Figure 2]b.
Figure 2: (a) The papule below the lower lip increased in size and became purulent; (b) A new tiny papule developed on the left hand.

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The incubation period of monkeypox infection ranges from 3 to 20 days, and the prodromal symptoms include fever, malaise, headache, and myalgias.[1],[2] Our patient presented with prodromal symptoms 6 days after monkeypox vaccination. He may have had risky sexual behavior before or immediately after vaccination. Based on a recent study of the 2022 outbreak, 4% (12 of 276) of the individuals who received post-exposure vaccination had a confirmed breakthrough monkeypox infection. Among them, 10 patients developed symptoms within 5 days after vaccination, whereas two patients developed infections at 22 and 25 days. None of the patients had severe infections or complications.[3] Another recent study reported that 77% of post-vaccination monkeypox infections occurred within 14 days after the first vaccination before the full protective effectiveness was achieved.[4]

Our patient had been diagnosed with HIV 10 years prior, and it was controlled well with bictegravir/tenofovir/emtricitabine. Two case series of monkeypox infections in Nigeria from 2017 to 2018 reported morbidities, such as larger skin eruptions and longer disease duration, and mortality among patients with untreated, advanced HIV/acquired immunodeficiency syndrome.[5],[6] These patients had relatively low CD4 counts (range: 20–357 cells/μL).[5] In contrast, patients with monkeypox with underlying HIV infection in the current outbreak presented with a relatively mild and limited course of the disease,[7] similar to our patient's clinical condition. Based on two case series, analyzing monkeypox-infected patients mainly diagnosed in Europe and America; 35%–41% of the individuals were living with HIV, and most were taking ART. The HIV viral load was undetectable in 78%–97% of cases, and the median CD4 count was approximately 670 cells/μL.[1],[2]

The United States CDC guidance recommends that post-exposure vaccination may prevent monkeypox onset or reduce the symptoms depending on the time of vaccination after monkeypox exposure.[8] The precise threshold for initiating vaccinia immune globulin intravenous and/or antiviral agents, such as tecovirimat, against monkeypox in patients with HIV remains undetermined. The relevant studies are scarce. The United States CDC guidance suggests considering treatment of monkeypox based on the severity of the disease and extent of immunosuppression and emphasizes the importance of continuing ART and precluding drug interactions in these patients.[8] Further, investigations on the indications for and efficacy of treatment against monkeypox are necessary.

In conclusion, our case expands the database of breakthrough monkeypox infections in patients with HIV who have received their first monkeypox vaccination. It is important to raise awareness of breakthrough monkeypox infections, especially within the immediate post-vaccination period.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for the images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al. Monkeypox virus infection in humans across 16 countries – April-June 2022. N Engl J Med 2022;387:679-91.  Back to cited text no. 1
    
2.
Patel A, Bilinska J, Tam JC, Da Silva Fontoura D, Mason CY, Daunt A, et al. Clinical features and novel presentations of human monkeypox in a central London Centre during the 2022 outbreak: Descriptive case series. BMJ 2022;378:e072410.  Back to cited text no. 2
    
3.
Michael T, Peiffer-Smadja N, Mailhe M, Kramer L, Ferre V, Houhou-Fidouh N, et al. Breakthrough infections after post-exposure vaccination against Monkeypox. medRxiv 2022.08.03.22278233. [Preprint] doi: https://doi.org/10.1101/2022.08.03.22278233.  Back to cited text no. 3
    
4.
Hazra A, Rusie L, Hedberg T, Schneider JA. Human Monkeypox virus infection in the immediate period after receiving modified Vaccinia Ankara vaccine. JAMA 2022;328:2064-7.  Back to cited text no. 4
    
5.
Ogoina D, Iroezindu M, James HI, Oladokun R, Yinka-Ogunleye A, Wakama P, et al. Clinical course and outcome of human Monkeypox in Nigeria. Clin Infect Dis 2020;71:e210-4.  Back to cited text no. 5
    
6.
Yinka-Ogunleye A, Aruna O, Dalhat M, Ogoina D, McCollum A, Disu Y, et al. Outbreak of human monkeypox in Nigeria in 2017-18: A clinical and epidemiological report. Lancet Infect Dis 2019;19:872-9.  Back to cited text no. 6
    
7.
Perez Duque M, Ribeiro S, Martins JV, Casaca P, Leite PP, Tavares M, et al. Ongoing monkeypox virus outbreak, Portugal, 29 April to 23 May 2022. Euro Surveill 2022;27:2200424.  Back to cited text no. 7
    
8.
O'Shea J, Filardo TD, Morris SB, Weiser J, Petersen B, Brooks JT. Interim guidance for prevention and treatment of Monkeypox in persons with HIV infection – United States, August 2022. MMWR Morb Mortal Wkly Rep 2022;71:1023-8.  Back to cited text no. 8
    

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Correspondence Address:
Meng-Sui Lee,
No. 33, Sec. 2, Zhonghua Road, Taipei 100
Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.DS-D-22-00136



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