EP247 - The First Report of Anal Stricture Secondary to Monkeypox Infection

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Purpose/Background: Historically, outbreaks of Monkeypox were short lived and limited to endemic tropical rainforest regions. The virus was transmitted through animal-to-human contact and then human-to-human contact with those infected. There has been mounting evidence that sexual contact is the most common mode of transmission. The risk of proctitis is said to be 5.5 times higher among patients who recently received anal intercourse. Severe anal pain is the most common symptom and physical findings of proctitis and anal/rectal ulcers that contained the virus are common. Imaging is notable for sigmoid, rectal and anal wall thickening, along with enlarged perirectal lymph nodes. To our knowledge, this is the first write up of a patient that developed an anal stricture after Monkeypox infection.

Methods/Interventions: A 31-year-old male who was HIV positive, compliant with his anti-viral medications, presented to the Emergency Department with chills and skin lesions after sexual contact with a partner who had Monkeypox. He was diagnosed with Monkeypox and presented again a month later to the ED with rectal bleeding and cramping abdominal pain. CT scan at this time showed circumferential thickening of the lower rectal wall that extended to the anus. He was planned to undergo colonoscopy with the gastroenterology team but did not follow up. He presented to the colorectal office seven months later after an exposure to the Monkeypox virus at his housekeeping job from contaminated bed sheets. His main complaints were difficulty with bowel movements, pain, bleeding, and feeling as though his anus was the size of a pinhole. Digital rectal exam noted anal stenosis to about 5mm and a finger was not able to be passed.

Results/Outcomes: The patient was taken to the operating room for an exam under anesthesia and anal dilation. Anal stenosis 2cm from anal verge was noted. This was dilated to 12mm with difficulty. A biopsy of the stenotic area showed benign mucosa with fibrosis and mild chronic inflammation. A sigmoidoscope revealed no residual proctitis.
He followed up in the office a month later and said his symptoms improved but was still having difficulty with bowel movements. He began anal dilations at home starting with Hegar dilators size 15 up to size 18. A month later he continued to have symptoms and went to the OR for an EUA. He was digitally dilated, and electrocautery was used to excise the scar so that a medium size Hill-Ferguson retractor could be accommodated.
At two weeks post-operatively, he was doing well and felt he could have normal bowel movements. About two months later he began to have symptoms again and returned to the OR a third time for an EUA. Electrocautery was used to remove the stricture and again he was dilated to about 3cm. It has been one month since his third procedure, and he is symptom free currently.

Conclusion/Discussion: It is surprising that there have not been previous reports in the literature of anal strictures after Monkeypox infections. As is known, inflammation in the rectum and/or anus can lead to strictures and difficulty with bowel movements. The thickening of the bowel wall seen on imaging that is consistent with proctitis after our patient’s infection led to his anal stricture. In our opinion, the best approach to treatment is serial exams under anesthesia with anal dilation and removal of the fibrotic tissue causing the stricture with electrocautery.