A 32-year-old female presented to our emergency department with odynophagia, bilateral neck pain and persistent fever for 15 days. She had not improved after a 7-day course of oral co-amoxiclav 875/125 mg every 8 h. On direct oropharyngeal examination, erythema and white ulcerative lesions in the posterior and lateral oropharyngeal walls were observed
(Fig.
1). From these lesions, swabs were collected. Endoscopy showed similar findings in the nasopharyngeal region, with intense swelling and erythema. Moreover, lesions in the posterior aspect of the left tonsil were observed. Cutaneous eruption or genital lesions were not observed. Computed tomography ruled out related complications and showed bilateral cervical lymphadenopathy. However, 4 days later (after 19 days with symptoms) the patient presented with pruritic vesicles and oedematous papules with umbilication and, in some of them, central crusting. These lesions were located under the lower lip, in both upper extremities (including hands), right scapula and right breast
(Fig.
2). Under suspicion of varicella infection, skin and mucosal swabs were collected and acyclovir 10 mg per kg every 8 h was started. However, three days later, polymerase chain reaction discarded varicella infection and, instead, monkeypox virus DNA was found. At confirmation, most lesions were resolving so specific antiviral therapy was not needed. A superadded bacterial infection was detected (
Streptococcus dysgalactiae and
Staphylococcus aureus grew from initial pharyngeal swabs) and treated combining intravenous co-amoxiclav and linezolid. Recommendations to avoid further spread of the virus were given by the department of preventive medicine and satisfactory clinical recovery was observed after two weeks.