Monkeypox without Exanthem

To the Editor: We report on two unvaccinated adult patients from the same household who had strikingly divergent clinical presentations after monkeypox infection. Although readily identifiable disease symptoms developed in both patients, one of them presented with a disseminated skin eruption that included more than 100 pocks, whereas the other had no evident eruption suggestive of monkeypox. Analysis of the findings in the latter patient revealed a rare, specific description of monkeypox without exanthem1 and illustrates the difficulty of relying on clinical algorithms alone for the diagnosis of atypical or vaccine-modified orthopoxvirus infections. Patient 1 (whom Reed et al. refer . . .