Active secondary penile ulcers in a 30-year-old cisgender man with HMPX.
Located at the base of the penile shaft is round 15-mm tender ulcer with clear serous drainage and slightly rolled borders that is surrounded by poorly demarcated erythema, imaged at lesion day 3. This lesion took 18 days to heal.
A second smaller ulcer overlies the foreskin of the distal penis that is 10 mm in diameter with a dark, dried center and surrounding poorly demarcated erythema, imaged at lesion day 6.
A third ulcer overlies the scrotum and is 8-mm, tender, nonpruritic, and associated with diffuse scrotal erythema and mild edema. It developed 12 days prior and was part of the primary crop of lesions. This lesion took 27 days to heal.
These ulcers are associated with tender bilateral inguinal lymphadenopathy. This was mistaken for syphilis, for which he received treatment empirically, prior to receiving the diagnosis of HMPX.
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.