A Novel Dermatological Presentation of Monkeypox: Case Report

ABSTRACT Mpox is an orthopoxvirus infection with an increasingly broad clinical spectrum since the 2022 global outbreak. While classic descriptions emphasize a systemic prodrome followed by centrifugal progression of macules to papules, vesicles, and pustules, recent cases have demonstrated fewer lesions with more frequent mucosal and genital involvement. Here, we present an atypical genital‐predominant case of mpox in a 34‐year‐old male. A 34‐year‐old uncircumcised man with HIV, prior HSV‐1, HSV‐2, gonorrhea, and syphilis presented to the emergency department for genital lesions. Four days earlier, he had been treated with intramuscular ceftriaxone for gonorrhea and was later discharged from an initial emergency visit with empiric acyclovir and fluconazole. Two days later, he returned with penile swelling, itching, and rash. On physical exam, the uncircumcised penis was markedly edematous and erythematous. Phimosis was present, and the foreskin was retracted with moderate resistance to reveal numerous coalescent umbilicated off‐white lesions nearly replacing the visible glans. Similar umbilicated lesions were identified at the base of the penis and right forearm, with a single lesion on the scalp. Mpox testing was positive and confirmed clade II infection. The patient denied systemic symptoms, lacked lymphadenopathy, and had unremarkable labs. Given his immunocompromised status, he was started on tecovirimat with good clinical improvement and discharged home for continued isolation. This case represents an extension in the range of presentation of mpox. While genital mpox, penile edema, and mpox‐associated phimosis have been described, this case is distinguished by dense coalescent off‐white umbilicated lesions nearly replacing the visible glans with acquired phimosis and minimal systemic symptoms. Recognition of this morphology may reduce diagnostic delay, limit transmission, and facilitate timely treatment.