In a report recently published in the Journal of Infection, scientists have presented the first documented case of co-infection with monkeypox virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and human immunodeficiency virus (HIV).
Study: first case of co-infection by monkeypox virus, SARS-CoV-2 and HIV. Image credit: joshimerbin/Shutterstock
background
Monkeypox is a zoonotic virus belonging to the Orthopoxvirus genus of the Poxviridae family. The virus is mainly endemic to the rainforest areas of central and western Africa. Recently, severe outbreaks of monkeypox infection have been detected in non-endemic countries around the world.
As of January 2022, more than 16,000 cases of monkeypox infection have been detected in more than 74 countries. Given these sudden outbreaks, the World Health Organization (WHO) has declared monkeypox a public health emergency.
Man-to-human transmission of the virus occurs mainly through close contact with infectious skin lesions, fomites, seminal fluids and oropharyngeal secretions. The most recent cases have been detected in men who have sex with other men. A relatively higher prevalence of monkeypox and HIV co-infections has also been observed.
The coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 still continues with considerable morbidity and mortality worldwide. Monkeypox and SARS-CoV-2 infections share several similar symptoms, including fever, headache, fatigue, and swollen lymph nodes. The co-existence of these pathogens in nature increases the risk of co-infection, which can further burden the global healthcare system.
Monkeypox, SARS-CoV-2 and HIV coinfection
The case report described in the article concerns a 36-year-old Italian man who spent five days in Spain in June 2022. During his stay, he had unprotected sex with men. Nine days after his return, he developed fever, sore throat, headache, fatigue, and enlarged lymph nodes. He tested positive for SARS-CoV-2 infection.
Afterwards, he developed severe skin rashes on his face and other parts of his body, followed by the formation of pustules. Given the severity of the illness, he visited the hospital’s emergency department, where he was subsequently referred to the infectious disease unit for admission.
In the hospital medical report, he mentioned having syphilis in 2019. In 2021, he was tested for HIV infection, but the report was negative. He also mentioned being treated with carbamazepine for bipolar disorder. He was diagnosed with COVID-19 in January 2022. Regarding vaccination, he reported that he received two doses of the COVID-19 mRNA vaccine (Pfizer) in December 2021.
Physical examination revealed spots and skin lesions on various parts of the body, including the perianal region. Modest enlargement of the liver and spleen and painful enlargement of the lymph nodes were noted.
Biochemical examination revealed increased C-reactive protein (CRP) and fibrinogen levels and an elevated prothrombin time. Chest X-ray revealed parenchymal hypodiaphany.
Biological samples were collected from their skin lesions and respiratory tract and subjected to reverse transcription-polymerase chain reaction (RT-PCR). The report confirmed the presence of monkeypox infection. He also tested positive for HIV. Genome sequencing of SARS-CoV-2 confirmed that it was infected with the omicron subvariant BA.5.1.
He was treated with 500 mg of sotrovimab intravenously. On day five after admission, almost all symptoms resolved, although he remained positive for SARS-CoV-2 and monkeypox virus. However, he was discharged from hospital and advised to self-isolate at home.
After eight days of discharge, he visited the hospital to be retested for monkeypox infection, which came back positive for the virus. Treatment for his HIV infection was started with a triple combination of dolutegravir, abacavir, and lamivudine.
importance
This case report describes the presence of monkeypox, SARS-CoV-2, and HIV co-infection in an adult man who had unprotected sex with men. Given the case findings, scientists suggest that patients with flu-like symptoms, as well as a recent history of travel to monkeypox epidemic regions, should be screened for both SARS-CoV-2 and for monkey pox, even if they do not have skin lesions or rashes.
Additionally, the case report highlights that monkeypox infection could spread primarily between humans through sexual transmission. This highlights the need for a thorough examination of sexually transmitted infections in patients with monkeypox infection.
The long-term presence of monkeypox virus in an oropharyngeal swab indicates that the patient may remain contagious even after resolution of symptoms.