The man was in Spain between June 16 and 20, where he had unprotected sex with other men. Nine days later, he developed a fever and suffered from a sore throat, fatigue, headaches and swollen glands.

Monkeypox virus, COVID-19 and HIV infections can occur simultaneously, says the report published in the Journal of Infection after a 36-year-old Italian man became the first documented case of co-infection with the three illnesses.

The Italian man was in Spain between June 16 and 20, where he had unprotected sex with other men. Nine days later, he developed a fever and suffered from a sore throat, fatigue, headaches and swollen glands.

On July 2, he tested positive for SARS-CoV-2, the virus that causes COVID-19. In the afternoon of the same day, a rash started to develop on his left arm. The following day, small, painful vesicles surrounded by an erythematous halo appeared on the torso, lower limbs, face and glutes. On July 5, due to a progressive and uninterrupted spread of vesicles that began to evolve into umbilicated pustules, he went to the emergency department of the University Hospital in Catania, Italy.

On admission, the patient reported having been treated for syphilis and bipolar disorder in the past. In September 2021, he had performed an HIV test with a negative result. He was already vaccinated for COVID-19 with two doses of the Pfizer vaccine, the last one in December 2021, and had been COVID positive in January 2022. He also reported having intercourse with men during his stay in Spain.

The patient tested positive for HIV-1 and the infection was relatively recent, the journal reports. “To note, the monkeypox oropharyngeal swab was still positive after 20 days, suggesting that these individuals may still be contagious for several days after clinical remission,” the report says.

“To date, no reports of co-infection with monkeypox virus and SARS-CoV-2 have been published,” the journal reports calling it the first such case.

Since January 2022, more than 16,000 people in over 74 countries have been affected by monkeypox, prompting the World Health Organization to declare this outbreak a public health emergency of international concern.

The monkeypox virus is currently taking the biggest toll on men who have sex with men, with 98 percent of global cases recorded among this group. The majority of cases were registered in gay or bisexual men, often suffering from other sexually transmitted infections. At the same time, COVID-19 is still a major cause of morbidity and mortality globally.

COVID-19 shares with monkeypox both the transmission by air droplets and the symptoms of fever, lymphadenopathy, headache, sore throat and fatigue.

Anyone exposed to the virus, however, may be infected. But the Italian man’s case, the journal reports, “emphasizes that sexual intercourse could be the predominant way of transmission for the monkeypox virus.”