Supplementary Material for: Concurrent Monkeypox, HHV8, and other opportunistic infections in a HIV patient with disseminated Kaposi sarcoma: a case report

Introduction. Human immunodeficiency virus (HIV) infection predisposes patients to opportunistic infections. Kaposi sarcoma (KS) is a soft tissue sarcoma caused by human herpesvirus-8 (HHV8). Patients with high HHV8 and HIV viremia can develop KS inflammatory cytokine storm (KICS), a rare condition characterized by severe sepsis-like symptoms and high mortality. Case Presentation. We present a patient with poorly controlled HIV and 2-weeks of fevers, dyspnea, abdominal pain, weight loss, and tender umbilicated plaques on the face, trunk, and extremities. Along with HIV, concomitant infections included HHV8, herpes simplex virus, cytomegalovirus, methicillin-resistant Staphylococcus aureus, adenovirus, and rhinovirus/enterovirus. Skin biopsy was positive for monkeypox. Lymph node biopsy was positive for monkeypox and HHV8, and morphologically consistent with KS. The patient also had pan-cytopenia with multiple increased inflammatory markers. Conclusion. This case highlights a diagnostic challenge. While numerous infections can cause inflammatory presentations with skin lesions and lymphadenopathy, only HHV8 is characterized by hypergammaglobulinemia. Further, in the setting of KS, HHV8-viremia is concerning for KICS. Recognizing this distinction is essential, as it shifts management from targeting infection to controlling the underlying inflammatory response.