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I appreciate Markus Müller and colleagues1 for evaluating images of mpox (formerly known as monkeypox). However, I have several concerns about the case presented in the Clinical Picture. First, a previous study revealed that percentages of positive PCR results were 99% for skin swab specimens, 70% for throat swab specimens, and 78% for anal swab specimens.2 Unlike oropharyngeal swabs and blood samples, viral DNA loads in lesion swab samples remain high despite evolving morphology of pustulae.3 Therefore, skin lesion specimens should be the first choice to detect monkeypox virus. However, the PCR tests for monkeypox virus in this patient were conducted in anorectal and oropharyngeal swabs instead of skin swabs. Second, localised lymphadenopathy in relation to lesion location is usually present in patients with mpox.2 But lymphadenopathy was not mentioned in this patient. In fact, lymphadenopathy is the most important sign differentiating mpox from smallpox and chickenpox.4 Third, concurrent sexually transmitted infections are also common among patients with mpox.2 But only the herpes simplex virus, Chlamydia trachomatis, and Neisseria gonorrhoea were tested for in tissue samples. Given the condomless penetrative and receptive anal intercourse by this patient, at least serological tests for syphilis and HIV should be conducted.

nfections are also common among patients with mpox.2 But only the herpes simplex virus, Chlamydia trachomatis, and Neisseria gonorrhoea were tested for in tissue samples. Given the condomless penetrative and receptive anal intercourse by this patient, at least serological tests for syphilis and HIV should be conducted. Finally, the positive PCR results for monkeypox virus in anorectal and oropharyngeal swabs were sufficient to make a diagnosis of mpox in this case. I consider that it is not necessary to conduct histopathological examination for this patient. Although histopathological examination can also determine the disease, it is traumatic and time consuming.