Active primary scrotal ulcer and partially scabbed penile lesion in a 30-year-old cisgender man with HMPX, both imaged at lesion day 12.
Located on the foreskin at the penile base is a 15 x 10 mm irregularly-shaped tender ulcer with an erythematous and wet base, early granulation tissue, and partial scabbing and no surrounding erythema. This was associated with mild edema of the foreskin. This ulcer was part of the primary crop of lesions and predated the systemic symptoms.
Located on the scrotum is an 8-mm tender, nonpruritic ulcer associated with diffuse scrotal erythema and mild edema that appeared at the same time as the penile ulcer. A second smaller scrotal ulcer, imaged here at lesion day 3, was part of a secondary crop of lesions.
Tender bilateral inguinal lymphadenopathy followed 2 days after the initial crop of lesions. This was mistaken for syphilis, for which he received treatment empirically, prior to receiving the diagnosis of HMPX. These lesions took 27 days to heal.
There was no history of immunocompromising conditions or medications. This man was on Truvada for HIV pre-exposure prophylaxis. He also received Imvamune for HMPX pre-exposure prophylaxis 3 days before illness onset.