In one day, a man was diagnosed with monkeypox, HIV, and COVID-19

• The first patient with COVID-19, monkeypox and HIV at the same time, was recently diagnosed in Italy.
• About a week after traveling to Spain, he came down with a fever and a sore throat, then a blistering rash.
• The man had unprotected sex with other men while on vacation, adding to the growing evidence of sexual transmission.

A man who tested positive for COVID-19 broke out in a rash later that day. According to a case study in the Journal of Infection, tests showed he also had monkeypox and HIV.

The 36-year-old patient, who was not identified by name in the report, is the first person in the world to test positive for all three infections in a single day, researchers said.

The Italian man reported that he developed fever, sore throat and headache nine days after returning from a trip to Spain. He tested positive for COVID-19 on July 2 – and his symptoms progressed from the typical presentation of the virus within hours.

First, the man noticed that a rash had started to form on his left hand. The next day small, painful blisters appeared on his face, trunk, legs and back. As the blisters continued to spread and turn into telltale pustules, the man decided to seek emergency care at a hospital in Catania, Italy.

On July 6 – just days after his first symptoms – the man was diagnosed with a combination of COVID-19, monkeypox and human immunodeficiency virus (HIV). Their case demonstrates how early symptoms of monkeypox and COVID may overlap, and underscores the importance of testing for other sexually transmitted infections after a diagnosis of monkeypox, the doctors wrote in the report.

‘Significant’ skin lesions and recent travel

When he reached the hospital, the man had scars on his body that looked like monkeypox in various stages of progress. Pus was raised on the palm of his hand and the side of his foot and was painted red. Other lesions had turned into scabs with depressed centers – one of the telltale signs of the virus.

The lesions also affected the patient’s perianal region, which has been typical in recent outbreaks. Experts doubt the possibility of sexual transmission of monkeypox because the outbreak has mainly affected men who have sex with men in their intimate areas.

Since the patient disclosed that she had unprotected sex with other men while on vacation to Spain, doctors tested her for monkeypox and ordered a full STI panel on her intake at the hospital. As per his medical history, the man also had syphilis in 2019 and was negative for HIV as per his last test in September 2021.

It is likely that her HIV infection was recent based on her sexual history and normal-appearing immune markers.

The doctors wrote in the report that this particular case “emphasizes that sexual intercourse may be the predominant mode of transmission”.

Man found treatment for COVID and HIV

Since this is the first known combination of COVID-19, monkeypox and HIV, doctors do not yet know how the trio of viruses can affect a patient’s condition.

After a few days in the hospital with almost all of his smallpox wounds, the Italian patient recovered well. He received an infusion of sotrovimab, a monoclonal antibody therapy, to treat his COVID infection and improved the next day.

By the sixth day in the hospital, most of the man’s symptoms had resolved. The swabs were still positive for COVID and monkeypox, but they had no new skin lesions and were home-isolated.

When he returned for a follow-up visit, the patient’s wounds were “almost completely healed, leaving a small scar.” They did not require treatment for monkeypox, although some physicians may recommend antivirals (namely tecovirimat, or TPOXX) for people with compromised immune systems.

The patient was placed on a combination antiretroviral therapy to maintain the function of her immune system and reduce the amount of HIV in her bloodstream. Like many other people who live with HIV, they will need to continue taking medication to keep the disease at bay.