Severe Monkeypox in an Immunocompromised HIV-Positive Patient: A Case Report of Extensive Necrotic Perineal Lesions and Ocular Involvement

Background: Monkeypox is a zoonotic virus that is usually self-limiting in most patients. However, in close to 40%, complications such as proctalgia, penile edema, and skin and anorectal abscesses may arise and warrant antiviral therapy, pain control, and antibacterial therapy in cases of bacterial co-infection. Co-infection of monkeypox infection and HIV is associated with significant morbidity and severe clinical manifestations with multi-organ involvement. Case Presentation: We present a 43-year-old HIV positive woman with advanced immunosuppression and monkeypox co-infection. The patient presented with extensive necrotic perineal lesions, ocular ulcers, and widespread skin involvement. Nystatin and fluconazole were used to manage suspected fungal superinfection. Albumin supplementation and intravenous Kabiven supported nutritional and fluid balance. Daily warm saline baths and calamine lotion provided wound hygiene and relief from pruritus. Morphine was administered to control pain effectively. Clindamycin, doxycycline, and ciprofloxacin targeted secondary bacterial infections. Enoxaparin was administered for thromboprophylaxis due to immobility and systemic inflammation. Conclusion: This case underscores the devastating impact of mpox in immunosuppressed patients, especially those with HIV and poor ART adherence. Despite the undetectable viral load, the patient’s low CD4 count promoted widespread necrotic lesions, ocular complications, and possible hepatic dysfunction, highlighting the need for careful organ monitoring. Comprehensive care, including ART adherence, remains essential to improving outcomes in such complex presentations.