Monkeypox Presenting as Proctitis in Men Who Have Sex With Men Michal Yakubovsky, 1,2, David Shasha, 1,2 Shelley Reich, 1,2 Luba Tau, 1,2, Nadav Friedel, 1,3 Ora Halutz, 4 Michal Dekel, 1,2 Suzy Meijer, 1,2 Ronen Ben-Ami, 1,2 and Yael Paran 1,2, 1 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 2 Department of Infectious Diseases and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 3 Division of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; and 4 Department of Clinical Laboratories, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel In our cohort of 70 patients of men who have sex with men (MSM) with monkeypox, more than one-third presented with proctitis. In two-thirds of proctitis patients, there was no typical rash upon presentation, and in one-fifth, there was no rash at all, making the diagnosis a challenge. A rectal swab for monkeypox polymerase chain reaction (PCR) can be diagnostic. Keywords. monkeypox; proctitis; sexually transmitted infection; rectal swab. Since early May 2022, cases of monkeypox (MP) have been de- tected in non-endemic countries across Europe, the United States, and Asia [1]. Cases have been reported primarily among males aged 18–50 years, and predominantly among men who have sex with men (MSM). The clinical features of monkeypox in the current outbreak appear to differ in several ways from the disease as previously described in African countries. Specifically, most patients present with a rash in the anogenital or perineal areas, with inguinal lymphadenopathy. Fever is absent in half of the patients, and a prodromal phase is absent in 20% [2]. Here we report cases of monkeypox presenting with proctitis as the predominant or solitary clinical syndrome. METHODS We retrospectively reviewed all patients diagnosed with mon- keypox virus (MPV) at the Tel Aviv Sourasky Medical Center, between 20 May 2022 and 16 July 2022. Cases of monkeypox proctitis were defined if they met all of the following criteria: 1. Patients of any age and sex who presented to the emergen- cy department (ED) of our institution with symptoms and signs compatible with proctitis or proctocolitis, as defined by the European Guideline on the Management of Proctitis, Proctocolitis, and Enteritis Caused by Sexually Transmissible Pathogens [3]. Proctitis signs and symp- toms included at least two of the following: mucopurulent anal discharge, anorectal bleeding, anorectal pain, and anorectal itch, sensation of rectal fullness or incomplete defecation, and tenesmus. 2. Detection of MPV DNA from a skin lesion, pharynx, or rectum using polymerase chain reaction (PCR). 3. A recent (up to 4 weeks) history of any sexual contact. Medical data were obtained from patient’s charts. Missing or unclear data were completed by phone interviews with patients and by reviewing outpatient medical records. For patients seen in our ED, PCR for MPV was performed on skin lesions, pharyngeal swabs, and rectal swabs as per judge- ment of the attending physician. We were not able to send PCR testing for sexually transmitted infections (STI’s) or syph- ilis serology, except for in those patients who were eventually admitted to the hospital. Patients discharged from the ED were recommended to have additional STI diagnostics per- formed in outpatient clinics. The study was approved by the Institutional Review Board of the Tel Aviv Medical Center with a waiver of informed consent (approval number TLV-0459-22). Pictures of patients were tak- en after obtaining written consent. RESULTS Between 20 May 2022 and 16 July 2022, 70 patients were diagnosed with MP at the Tel Aviv Sourasky Medical Center. Of these, 26 pa- tients (37.1%) had signs and symptoms of proctitis. Patients’ char- acteristics and clinical manifestations are presented in Table 1. Median patient age was 34 years (range 24–53 years). Anal pain was the most common symptom of proctitis. In 11 patients (42.3%), symptoms and signs of proctitis preceded the skin rash, appearing at a median of 3 days (range 1–7 days) before the rash. In six patients (23%) proctitis was the only clinical manifes- tation, without them ever developing any rash. Two patients had no available data regarding the timeline of the onset of symptoms. In total, 17 patients (65.3%) did not have any typical skin or mucosal lesions when proctitis symptoms began. Three patients with proctitis (11.5%) were found to have an anal mass protruding from the rectum accompanied by excru- ciating pain (Figure 1). One of these patients had a positive MPV PCR from a rectal swab taken directly from the anal mass. In addition to these patients, another 3 patients com- plained of having a feeling of a new anal mass, but no mass Received 21 July 2022; editorial decision 31 August 2022; published online 6 September 2022 Correspondence: M. Yakubovsky, Department of Infectious Diseases and Infection Control, Tel Aviv Sourasky Medical Center, Weizmann 6, Tel Aviv, Israel (michalya@tlvmc.gov.il). Clinical Infectious Diseases ® © The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions @oup.com https://doi.org/10.1093/cid/ciac737 BRIEF REPORT • CID • 1 Clinical Infectious Diseases BRIEF REPORT