A 31-year-old male patient, previously healthy and living in Liberia, Africa for the past 7 months, presented to our dermatology clinic with a 10-day history of scrotal edema and a vesicular rash. The rash was pruritic and associated with a low-grade fever. It started in the pubic area and then spread to involve the penile shaft and scrotum, with worsening painful scrotal edema and sore throat. He took doxycycline 100 mg twice per day for 5 days without improvement. He reported being monogamous with his wife for many years. He denied dysuria, hematuria, or hematochezia. He also reported no known contact with animals or symptomatic individuals during his stay. Physical examination showed severe tender penile and scrotal edema and erythema, with hard swollen lymph nodes in the inguinal area, more prominent on the right side, without crepitus or fluctuance (Figure 1). Multiple pinkish umbilicated papules were present on the pubic area, penile shaft, and scrotum, some of which were crusted (Figures 1 and 2). Laboratory tests showed a normal leukocyte count (7.96 × 10⁹/L), mild thrombocytopenia (154 × 10³/µL), elevated C-reactive protein (18.5 mg/dL), and normal creatinine (1.02 mg/dL). Blood cultures, skin bacterial cultures, and urinalysis were normal. Sexually transmitted infection screening was negative for hepatitis B, hepatitis C, syphilis, and genital herpes simplex virus types 1 and 2. Scrotal Doppler ultrasonography showed severe scrotal swelling. Both testes were symmetrical and at the upper limits of normal size, with slightly increased vascularity and mild bilateral hydrocele. Computed tomography of the pelvis showed a prominent and edematous scrotum with thickening of the skin and subcutaneous tissue. Fat stranding involved the cremasteric and inguinal canal subcutaneous tissues, with involvement of a few inguinal lymph nodes. These findings were suggestive of cellulitis. Scrotal Cellulitis Associated with mpox Infection. Mpox polymerase chain reaction from swabs of penile shaft and scrotal lesions confirmed mpox infection. The patient was started on intravenous vancomycin 1 g twice daily, along with scrotal elevation and pain management with paracetamol 1 g every 8 h. No targeted antiretroviral therapy was initiated due to its unavailability in Lebanon. Ten days after the initiation of antibiotic therapy, marked improvement in scrotal edema and healing of the vesicles were noted. Monkeypox virus (MPXV) is a double-stranded DNA virus of the Orthopoxvirus genus. It is the causative agent of the zoonotic infection known as monkeypox, recently renamed mpox. The most recent global outbreak began in May 2022 and was designated a Public Health Emergency of International Concern by the World Health Organization on July 23, 2022. A contributing factor to the resurgence of mpox is the decline in immunity following the discontinuation of smallpox vaccination programs 1, 2. MPXV transmission occurs from human-to-human and animal-to-human through direct contact with secretions and exudates, most commonly during sexual contact, or via exposure to large respiratory droplets. Men who have sex with men constitute the majority of the affected group compared with the general population 2. Mpox infection typically begins with a nonspecific flu-like prodromal symptoms, such as fever, headache, fatigue and myalgia, followed by the development of a characteristic vesiculopustular eruption which is the result of extensive viral replication within keratinocytes, leading to cell necrosis and the formation of fluid-filled vesicles and pustules 3. A recent dermatology-focused study has further highlighted the polymorphic nature of the eruption and the frequent involvement of genital and perianal areas during the 2022 outbreak 4. The current mpox outbreak revealed a broader spectrum of both cutaneous and extracutaneous manifestations compared with previous endemic outbreaks. Lesions may appear in various stages of evolution, and several new clinical features have been described, including proctitis, dysphagia, penile edema, and secondary bacterial cellulitis 5. Genital edema has also been reported as a manifestation directly associated with mpox infection. For example, scrotal edema was observed in approximately 11% of patients in a large clinical series of mpox cases 2, and genital edema was reported in up to 12% of patients in dermatology-focused cohorts 4. In this report, we present a case of severe scrotal edema in the setting of mpox infection. The differential diagnosis of acute scrotal edema is broad and includes anatomic causes (e.g., testicular torsion and thrombosed varicocele) as well as infectious etiologies (e.g., epididymitis, orchitis, and Fournier's gangrene) 6. In the evaluation of patients presenting with genital ulcerations, these lesions can result from multiple sexually transmitted pathogens; physical examination alone is insufficient to reliably determine the etiology, making appropriate STI diagnostic testing essential even in patients who deny classic risk factors or report a monogamous relationship 7. Given our patient's constellation of symptoms and the acute onset of scrotal and penile edema in association with a mpox lesion, bacterial cellulitis should be considered as a potential cause of clinical worsening, despite the absence of leukocytosis or fever. Notably, the patient demonstrated clinical improvement within 48 h of intravenous vancomycin therapy, even in the absence of leukocytosis, which may support the possibility of a secondary bacterial infection. However, given that scrotal and genital edema have been previously reported as direct manifestations of mpox infection, it is also possible that the edema observed in our patient was multifactorial, reflecting both the underlying viral infection and a potential secondary bacterial process 2, 4. Cellulitis and other deep skin infections are uncommon complications of mpox; however, the ulceration and crusting of the cutaneous lesions can serve as an entry point for secondary bacterial infection 8. Opportunistic pathogens from colonizing skin flora can cause soft tissue infections when the epithelial barrier is disrupted by cutaneous lesions of mpox. When oral antibiotic therapy directed against streptococcal and staphylococcal species fails to halt disease progression, intravenous antibiotics may be required, with consideration of broader coverage to include potential gram-negative and anaerobic organisms 9. Multiple therapeutic agents have been evaluated for the treatment of mpox during the 2022 global outbreak. In mild, uncomplicated cases, supportive and symptomatic treatment is generally sufficient. Tecovirimat remains the most widely used and clinically preferred option and is recommended for severe or high-risk cases of mpox. Brincidofovir and cidofovir and Vaccinia immune globulin represent second-line therapeutic options in cases of severe disease or suspected resistance to tecovirimat 10, 11. It should also be noted that access to the above antiviral agents remains limited in many settings, including Lebanon, which may further restrict their clinical use. In conclusion, we present a case of mpox infection complicated by acute-onset scrotal and penile edema. Although secondary bacterial cellulitis should be considered in patients presenting with worsening genital swelling, clinicians should also recognize that genital and scrotal edema may represent a direct manifestation of mpox infection itself. Dermatologists should remain vigilant for cellulitis arising in the context of mpox to ensure accurate diagnosis and timely management, thereby preventing potential complications. Hamad El Hajj: writing, drafting, editing, methodology, diagnosis, and management. Vera Al Baaklini: writing, diagnosis, and management. Dima Jeha: drafting and editing. Alfred Ammoury: investigation, validation, supervision, writing – review, and editing. The authors have nothing to report. The patient in this manuscript has given written informed consent for participation in the study and the use of his de-identified, anonymized, aggregated data and his case details (including photographs) for publication. Ethical Approval: not applicable. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Hajj et al. (Wed,) studied this question.