Ocular Mpox In Immunocompetent Patient

To document the clinical presentation, and ocular features of the latest worldwide outbreak of MPox (recently renamed from Monkeypox). To highlight importance of early identification, investigation and illustrate potential side effects of treatment.

Self-referral in casualty department of tertiary referral centre.

32-year-old immunocompetent male presented to casualty with unilateral eye redness and discharge. Accompanied by pharyngitis, painful lymphadenopathy. He was treated as viral conjunctivitis. He reattended 6-days later with pseudomembranous conjunctivitis, and started g. dexamethasone. He had blurred vision and “snail-tracks” over his conjunctiva; accompanied by maculopapular rash all over his body and inguinal region, multiple well-circumscribed skin lesions with central umbilication. His eye showed mucopurulent discharge, multiple raised, serpiginous lesions on the conjunctiva. There was limbitis and an ulcerative plaque adjacent to inferotemporal cornea. He was admitted for isolation and started on Tecovirimat and g. Moxifloxacin.

Patient developed acute transaminitis 5-days after commencing treatment, likely secondary to Tecovirimat. Liver function tests improved upon early cessation of Tecovirimat. Patient was discharged after 1-week, following satisfactory improvement in systemic symptoms and resolution of skin lesions. The resolution of ophthalmic signs and symptoms lagged behind the systemic symptoms. The area of limbitis associated with inferotemporal corneal keratitis showed gradual resolution with tapering steroids over 4-weeks. Convalescent viral PCR swabs of all skin lesions was negative 3-weeks following admission.

Early diagnosis with viral-PCR in cases with high index of suspicion is warranted in the global outbreak, for case isolation, as well as targeted treatment. Tecovirimat is effective in treating systemic symptoms, however, ocular penetration is less robust. Topical steroids may exacerbate symptoms and delay resolution of keratoconjunctivitis. This case highlights the side effects of treatment, and documents the MPox phenotype. Conjunctivitis can predate systemic skin lesions, frontline healthcare workers including ophthalmologists need to recognise the signs and symptoms. The serpiginous conjunctival lesions are rarely seen in other kerato-conjunctival conditions and we postulate that this could be pathopneumonic for Mpox conjunctivitis.