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A Dome-Shaped Eyelid Nodule in a Young White Man

To identify the key insights or developments described in this article
1 Credit CME

A 27-year-old White man presented with a recent onset of malaise, chills, night sweats, and sore throat with difficulty swallowing. He also reported redness of his right eye with watery discharge. He developed a skin rash affecting his trunk, limbs, and genitalia within the previous week. His medical history was noncontributory, except for allergic rhinitis, for which he was prescribed fexofenadrine pro re nata. His visual acuity was 6/6 in both eyes. Examination of his right eye revealed erythematous swollen eyelids. A slightly raised dome-shaped umbilicated nodule, of approximately 3 mm, was present on his medial one-third lower eyelid margin, with a similar lesion developing on the corresponding upper eyelid margin (Figure). A vesicular lesion was also present on the caruncle and there was global conjunctival hyperemia, mostly pronounced nasally and around the lesions (Figure, B). There were no signs of corneal involvement, and the anterior chamber was quiet. The left eye was normal. Results of fundus examination in both eyes were normal. No preauricular or submandibular lymph node involvement was noted, but cervical lymph nodes were enlarged. The pharynx was erythematous and swollen with white pus patches. The skin lesions were dome-shaped papules, round, pinkish-white in color, surrounded by an erythematous area. Full blood cell count and tests for HIV, AIDS, and syphilis were ordered. Conjunctival swabs and eyelid vesicle fluid were taken for polymerase chain reaction testing. Swabs of the upper respiratory tract were also taken.

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Ocular manifestation of Monkeypox infection

A. Isolate the patient and notify public health authorities

A 2022 outbreak of human monkeypox (HMPX) has recently gained global attention. As of July 1, 2022, there were 5783 total confirmed cases in 52 locations, the majority of whom were reported in Europe, with 1235 confirmed cases in the United Kingdom. A few different variants have been detected. Most of cases occurred in young men after close contact with infected individuals.1

HMPX is a zoonosis caused by infection with the Monkeypox virus, an Orthopoxyvirus of the Poxvyridae family. The disease was first described in central Africa2 in 1970 and has historically affected some of the poorest communities in the world,3 being rarely exported from the African continent.4 Commonly reported clinical features include fever, headache, muscle aches, backache, swollen lymph nodes, chills, exhaustion, and a skin rash, characterized by pimple- or blisterlike lesions that appear on the face, hands, feet, chest, genitals, or anus. The illness typically lasts 2 to 4 weeks. Complications include pneumonia, encephalitis, and secondary bacterial infections.4,5

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Article Information

Corresponding Author: Eleonora Micheletti, MD, Oxford Eye Hospital, John Radcliffe, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, United Kingdom (eleonora.micheletti@gmail.com).

Published Online: September 7, 2022. doi:10.1001/jamaophthalmol.2022.3741

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

Centers for Disease Control and Prevention. Monkeypox signs and symptoms. Accessed August 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/index.html.
Marennikova  SS , Seluhina  EM , Mal’ceva  NN , Cimiskjan  KL , Macevic  GR .  Isolation and properties of the causal agent of a new variola-like disease (monkeypox) in man.   Bull World Health Organ. 1972;46(5):599-611.PubMedGoogle Scholar
McCollum  AM , Nakazawa  Y , Ndongala  GM ,  et al.  Human monkeypox in the Kivus, a conflict region of the Democratic Republic of the Congo.   Am J Trop Med Hyg. 2015;93(4):718-721. doi:10.4269/ajtmh.15-0095PubMedGoogle ScholarCrossref
Learned  LA , Reynolds  MG , Wassa  DW ,  et al.  Extended interhuman transmission of monkeypox in a hospital community in the Republic of the Congo, 2003.   Am J Trop Med Hyg. 2005;73(2):428-434. doi:10.4269/ajtmh.2005.73.428PubMedGoogle ScholarCrossref
Huhn  GD , Bauer  AM , Yorita  K ,  et al.  Clinical characteristics of human monkeypox, and risk factors for severe disease.   Clin Infect Dis. 2005;41(12):1742-1751. doi:10.1086/498115PubMedGoogle ScholarCrossref
Hughes  C , McCollum  A , Pukuta  E ,  et al.  Ocular complications associated with acute monkeypox virus infection, DRC.   Int J Infect Dis. 2014;21:276-277. doi:10.1016/j.ijid.2014.03.994Google ScholarCrossref
Leung  AKC , Barankin  B , Hon  KLE .  Molluscum Contagiosum: an update.   Recent Pat Inflamm Allergy Drug Discov. 2017;11(1):22-31. doi:10.2174/1872213X11666170518114456PubMedGoogle ScholarCrossref
Tsatsos  M , MacGregor  C , Athanasiadis  I , Moschos  MM , Hossain  P , Anderson  D .  Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents.   Clin Exp Ophthalmol. 2016;44(9):824-837. doi:10.1111/ceo.12785PubMedGoogle ScholarCrossref
World Health Organization. Monkeypox. Accessed August 23, 2022. https://www.who.int/news-room/fact-sheets/detail/monkeypox.
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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