Sudden Anal Discharge and Rectal Pain in 30-Year-Old Man

What is causing this 30-year-old man's mucopurulent anal discharge, cramping rectal pain, and sensation of needing to have a bowel movement even after emptying his bowel?

That's what physicians at La Paz University Hospital in Madrid, Spain, were trying to determine, as Rafael Escudero-Tornero, MD, and colleagues explained in their report of the case in JAMA Dermatology. When the patient presented to clinic a week after the onset of these symptoms, he noted that 2 days earlier, he had also developed itchy bumps around his anus.

Physical examination revealed multiple small vesicles and papulovesicles measuring less than a centimeter and central necrosis surrounding the anal opening. The patient seemed otherwise healthy; he was afebrile and said he had no fatigue, headaches, or joint or muscle pain. Clinicians did note palpable lymphadenopathy in the inguinal basin, however.

The patient reported having traveled to Gran Canaria island in Spain the week before his symptoms started, and having an unprotected sexual encounter with another man 5 days before symptom onset.

Clinicians obtained samples from the rectum and perirectal skin; lab test results were negative for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex virus. Findings of blood tests for rapid plasma reagin and HIV were also unremarkable.

Given the possibility that the patient had monkeypox, clinicians obtained a swab from an intact vesicle, and genomic amplification testing came back positive. The team counseled the patient about self-isolation measures and started him on treatment to address his itchy lesions and anal pain and discharge. A week later, the vesicles were crusting and the proctitis was resolved.

Discussion

Escudero-Tornero and co-authors noted that in the current outbreak of monkeypox -- first reported in May 2022 in non-endemic countries -- cases frequently present with isolated genital and perianal presentations rather than a generalized rash, in contrast to previous manifestations.

Initially identified about 70 years ago, monkeypox is considered endemic in some areas of central and western Africa. In most cases, infection causes a widespread rash "characterized by lesions that evolve through multiple stages, including macular, papular, vesicular, and pustular morphologies with umbilication," the authors wrote. "When diffuse, the rash follows a cephalocaudal progression, with lesions at a single site often in the same phase of development."

In more typical cases, the group explained, systemic symptoms such as fever, headache, joint stiffness, muscle pain, and lymphadenopathy have accompanied the skin manifestation.

According to the World Health Organization's interim rapid response guidance published in June 2022, the rash due to monkeypox can be confused with that due to varicella zoster virus, but can be distinguished by the following differences. The rash caused by varicella zoster virus:

• Generally progresses more quickly

• Is more centrally located than the centrifugal distribution of monkeypox

• Typically is seen in multiple stages of development (versus the same stage usually seen with monkeypox)

• Does not generally involve the palms and soles of the feet

• Is not associated with lymphadenopathy, a hallmark of monkeypox

Despite the clinical differences between the two diseases, a study from the Democratic Republic of the Congo reported co-infection with monkeypox/varicella zoster virus with an incidence of 10-13%.

Monkeypox develops over 1 to 2 weeks after exposure, Escudero-Tornero and co-authors said, noting that in some outbreaks reported in the U.S. and the U.K. the illness has resolved on its own without the need for treatment.

Transmission can occur through direct contact with the lesions or respiratory secretions, or result from prolonged intimate contact, Escudero-Tornero and co-authors noted, cautioning that despite an association with sexual activity between men, close contact with an infected individual can result in transmission to anyone.

Pointing to the rapid spread of the recent outbreak, the team urged clinicians to include the virus in the differential diagnosis of umbilicated papules and vesicles, whether spread throughout the body or localized. A thorough sexual history should be taken, and consideration should be given to any possible previous exposure to affected individuals.

Similar symptoms may be caused by localized or generalized herpes virus, as well as other viral exanthems and syphilis, the group noted; in addition, in cases where skin symptoms are limited to the anogenital area, clinicians should consider the possibility of other sexually transmitted infections and potential concomitant infections, and test patients accordingly.

Following diagnosis, patients with monkeypox should receive symptomatic treatment and be advised to follow current WHO recommendations, including droplet and contact isolation for 21 days.

In people with severe disease, a heavy rash may be associated with exfoliation similar to partial thickness burns, which can lead to dehydration and protein loss. In these cases, clinicians should estimate the percentage of the body affected; the WHO notes that exfoliation affecting more than 10% of the body is concerning.

Treat exfoliation as burns would be managed, the guidelines state: minimize fluid loss, promote healing, and ensure adequate hydration and nutrition. In severe cases, consult with appropriate specialists and consider bedside or surgical debridement as needed. Pets should also be isolated, the WHO advises.

"Further research will be needed to assess other emerging therapeutic strategies in treating this new form of a long-known disease," the case authors concluded.

Comment