be unroofed • Lesions were painful • No inguinal lymphadenopathy Friday, June 3 – Day 2 – Patient Testing and Treatment ▪ Routine Pre-exposure HIV Prophylaxis (PrEP) Clinic human immunodeficiency virus (HIV)/Sexually Transmitted Infections (STI) testing was done – including a rapid plasma reagin (RPR) test • A herpes simplex virus (HSV) culture was collected ▪ Empirically started on treatment for his first clinical episode of genital herpes ▪ Anticipatory guidance and counseling was provided for other possible diagnoses – including molluscum contagiosum and monkeypox ▪ Monkeypox swabbing was discussed but not done at that time because there were no prodromal symptoms and only 4 days had passed between the sex party and the onset of symptoms ▪ Plan to return to clinic next week to discuss results and reassess symptoms ▪ Patient agreed to sexual abstinence pending results and a definitive diagnosis Penile Lesions – Sunday, June 5 – Day 4 Monday, June 6 – Day 5 ▪ Patient called the clinic to discuss lab results and provide update on symptoms ▪ Lab results • RPR non-reactive, HSV culture negative • Pharyngeal and rectal NAAT were negative for both chlamydia and gonorrhea • Urine NAAT was positive for chlamydia (and negative for gonorrhea) ▪ Symptom evolution • Genital lesions had increased in size and number and had become more painful – in addition, his penis and foreskin had become more edematous • Additional lesions elsewhere on his body • Subjective fever for two nights associated with fatigue and decreased appetite ▪ He learned that one of his partners at the NYC sex party lives in Toronto, was symptomatic, and had received a monkeypox diagnosis Tuesday, June 7 – Day 6 – Patient History ▪ The patient returned to clinic (with his most recent sex partner) ▪ Pertinent index patient history: • Reported 10 male sex partners in past the 90 days and 40 in the past year • Reported using the substances ecstasy and ketamine in the past 30 days • Sex with anonymous and pseudo-anonymous partners (i.e., only knew partners by their App profile name) • Engaged in receptive and insertive oral and anal intercourse; never used condoms • Prior history of chlamydia, gonorrhea, and syphilis infections Tuesday, June 7 – Day 6 – Patient Exam Findings ▪ Mouth with oral lesion • Small ulcerated area in upper right rear oral cavity; painful when swabbed Tuesday, June 7 – Day 6 – Patient Exam Findings, 2 ▪ Chin lesion • One lesion with white rim, dark center, erythematous base Tuesday, June 7 – Day 6 – Patient Exam Findings, 3 ▪ Penis – uncircumcised with multiple white lesions with umbilicated center • Edematous foreskin and distal end of penis • Patient unable to retract foreskin • Area generally painful • Possible white urethral discharge noted Tuesday, June 7 – Day 6 – Patient Testing and Treatment ▪ All three of the patient’s lesions were swabbed for monkeypox testing ▪ The patient was started on doxycycline 100 mg by mouth twice a day for 7 days for urogenital chlamydia treatment ▪ The patient was instructed to call the clinic in the next day or two to discuss results and reassess symptoms Tuesday, June 7 – Day 6 – Partner History ▪ The partner, a 23-year-old White MSM, presented for evaluation and reported onset of new rash ▪ Pertinent partner history: • They were last together Wednesday, June 1 – one day before the index patient’s symptoms started • Partner reported 3 male sex partners in the past 90 days and 10 in the last year • He reported sex with anonymous and pseudo-anonymous partners • He engaged in receptive and insertive oral and receptive anal intercourse; never used condoms • History of chlamydia and gonorrhea in the previous year Tuesday, June 7 – Day 6 – Partner Exam Findings ▪ Skin of right axilla • One nodular firm papule (~0.5 cm) right axillae Tuesday, June 7 – Day 6 – Partner Exam Findings, 2 ▪ Chest • Five papular, mildly erythematous lesions across chest in varying sizes (largest ~0.5 cm) • One lesion with white rim, dark center, erythematous base Tuesday, June 7 – Day 6 – Partner Exam Findings ▪ Buttocks • One very small papule on skin of left lower buttock Tuesday, June 7 – Day 6 – Partner Exam Findings, 2 ▪ Buttocks • One very small papule on skin of left lower buttock ▪ Lymph nodes • No axillary, supraclavicular, or inguinal adenopathy Tuesday, June 7 – Day 6 – Partner Testing and Treatment ▪ All three of partner’s anatomic sites with lesions (right axilla, chest, left buttock) were also swabbed for monkeypox testing ▪ The partner was started on doxycycline 100 mg by mouth twice a day for 7 days as a contact to chlamydia Wednesday, June 8 – Day 7 – Test Results ▪ All three sites of the patient’s lesions tested Orthopoxvirus positive ▪ All three sites of the partner’s lesions tested Orthopoxvirus negative* *Specimen results were reported as: positive, negative, or QNS | TNP (meaning that there was not enough DNA material to run the test). The partner’s specimen was adequate enough to report a negative result. ▪ The patient called the clinic with an update that the number and size of the lesions had continued to increase and that he was no longer able to urinate due to the pain and swelling ▪ The clinic staff communicated with a local emergency department to have the patient evaluated ▪ The patient was treated with oxycodone and phenazopyridine ▪ He was able to void spontaneously after the pain was