A 30-year-old man, diagnosed 5 days earlier with human immunodeficiency virus infection (HIV) and atypical pneumonia, presented with a 10-day history of skin lesions. Physical examination revealed painful superficial ulcers on the oral mucosa and oropharyngeal region that were round, with a white-yellowish border and a grayish base, measuring between 0.5cm and 1.3cm in diameter. Furthermore, detachable whitish oral plaques and bilateral submandibular lymphadenopathy were observed. Serologic analysis revealed a CD4 lymphocyte count of 14cells/mm3 and an HIV viral load >1,000,000copies/mL. The diagnostic impression was pseudomembranous candidiasis and infection by the Monkeypox virus (later confirmed by PCR testing). In the differential diagnosis, recurrent aphthae and viral infections caused by Herpes simplex virus and Varicella-zoster virus were considered. The patient was initially treated with amphotericin B and trimethoprim/sulfamethoxazole, followed by fluconazole after the oral examination. Antiretroviral therapy was deferred to avoid the development of Immune reconstitution inflammatory syndrome. Oral candidiasis was controlled on the third day of treatment. However, the patient developed complications from pneumonia and died two weeks later (Fig. 1).

Fig. 1