*PURPOSE: Monkeypox is a source of worldwide public health concerns. Presentations and outcomes of monkeypox infection in solid organ transplant recipients are unknown. *METHODS: We report a case of monkeypox infection in a kidney transplant recipient (KTR) who had ESRD secondary to HIV-associated nephropathy (HIVAN). *RESULTS: A 44-year-old male presented with difficulty in urination, diarrhea, and rash of 1-week duration. He underwent deceased donor renal transplant in June 2019 and again in August 2020 for allograft failure due to rejection. His creatinine was stable at 2.5mg/dL. Maintenance immunosuppression included tacrolimus, mycophenolate mofetil (MMF), and prednisone. His last homosexual encounter was > 20 years ago. On examination, he was found to have lower lip and oropharyngeal ulcers and disseminated 1-2 cm papulovesicular skin lesions over his entire body including the palms and soles (FIGURE 1). He had urinary retention necessitating catheterization. CT abdomen showed severe proctitis with rectal edema causing colonic obstruction and reactive adynamic small bowel obstruction (FIGURE 2). His HIV RNA was undetectable and CD4 count was 145 cells/mL. All cultures, swabs, and serologies for STDs were negative except for orthopoxvirus DNA swab. Oral Tecovirimat, a novel inhibitor of the orthopoxvirus VP37 envelope-wrapping protein, was started. MMF was held, prednisone was increased to 10mg daily, and tacrolimus dose was modified to target a trough level of 4-6ng/mL. The patient later had worsening eosinophilia (absolute eosinophil count 1.58 x 10^9/L) and monocytosis (absolute monocyte count 2.83x 10^9/L). After a thorough workup, this was attributed to tecovirimat which was stopped after 9 days of therapy. His allograft function was stable. He had progressive umbilication, desquamation, and formation of pitted scars within 2-3 weeks (FIGURE 1). *CONCLUSIONS: 1) The presentation of monkeypox seemed more severe in this KTR including disseminated skin rash, diffuse mucosal involvement, urinary retention, proctitis, and bowel obstruction. 2) Allograft function was not affected by the illness or antiviral therapy. 3) Optimal immunosuppression management is still unknown. Case series are needed to confirm this observation. [

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]CITATION INFORMATION: Attieh R., Brumble L., Elwasila S., Wadei H. Disseminated Monkeypox Infection in a Kidney Transplant Recipient AJT, Volume 23, Issue 6, Supplement 1.

Rose Mary Attieh MD

Mayo Clinic

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