A 36-year-old man in Italy appears to be uniquely unlucky, after he was hospitalized and diagnosed with covid-19, monkeypox, and HIV over a span of a single week in July. Thankfully, his covid and monkeypox co-infections did successfully clear up without issue, and he has since been placed on HIV treatment.
His doctors describe this unfortunate medical tale in a case report published last week in the Journal of Infection. According to the report, the man first became ill with a fever, sore throat, and headache on June 29, nine days after having returned from a trip to Spain. On July 2, he tested positive for the SARS-CoV-2 coronavirus, but that same day, he also noticed a rash starting to develop on his left arm. Over the next few days, the rash turned into small, painful blisters that spread along his face, torso, lower limbs, and glutes. On July 5, he sought care at the emergency department of a local hospital in Catania, Italy, where he was then admitted into the infectious disease unit.
Given the man’s symptoms and recent travel to Spain, doctors quickly suspected monkeypox infection and collected samples for testing (the country was one of the first to report cases this year). While in Spain, the man also reported having condomless sex with other men, which has been a risk factor for monkeypox during the current outbreak. Finally, on July 6, the man tested positive for monkeypox, HIV, and the coronavirus—specifically, the Omicron BA.5.1 variant.
“To date, no reports of co-infection with monkeypox virus and SARS-CoV-2 have been published,” the authors wrote. “Therefore, in this study we present the clinical features and diagnostic procedure of the first documented case of co-infection with monkeypox virus, SARS-CoV-2, and HIV-1.”
Due to their respective incubation periods, the man could have caught the coronavirus and monkeypox at the same time. It’s thought to take anywhere from three to 17 days after exposure for monkeypox symptoms to appear, and around two to 14 days for covid-19 symptoms to show up (though the incubation period has likely gotten shorter on average for Omicron). As for the HIV infection, the man told doctors that he tested negative for it in September 2021. And since his CD4 lymphocyte count was still normal, it’s likely that this infection was caught recently as well. It can take 10 to 90 days following exposure to test positive for HIV, depending on the test used, and early flu-like symptoms may appear within a few weeks to a month.
Though co-infections can sometimes contribute to more severe illness, it’s not clear whether that played any role in this case. By day three of the man’s hospitalization, most of his rashes started to crust over; by day five, his symptoms had almost completely resolved and he was sent home soon after. By July 13, he was no longer testing positive for the coronavirus, and on July 19, a follow-up visit to the doctors revealed that his crusty rashes had healed over almost completely, though he was still positive for monkeypox on a swab test. He was also started on a standard combination therapy for HIV, which is known to be very effective at keeping the chronic infection at bay when taken regularly.
While monkeypox may be able to spread to others through any kind of prolonged close contact, evidence continues to show that the vast majority of cases during this outbreak have been transmitted during sex, and most often among gay and bisexual men who have had multiple recent partners—perhaps both from close contact with contagious rashes and through infectious semen or other bodily fluids. Because the covid-19 pandemic is still ongoing and monkeypox cases are on the rise, the authors say that doctors should be aware of the possibility of co-infection in high-risk groups. They also add that their case emphasizes the predominant role that sex could be having in spreading monkeypox.
“Therefore, complete STI screening is recommended after a diagnosis of monkeypox,” they wrote.