Conjunctivitis in an Individual With Monkeypox

Ocular manifestations of mpox

PURPOSE OF REVIEW

To highlight the clinical features of mpox with an emphasis on ocular manifestations and to review treatment options for this re-emerging infectious disease.

RECENT FINDINGS

Ocular involvement of mpox varies by clade. The most recent 2022 outbreak appears to be associated with fewer conjunctivitis cases compared to previous outbreaks. However, the ocular findings occurring during this newly emerging clade can be visually threatening and include cases of keratitis, rapidly progressing scleritis, and necrotizing periorbital rashes.

SUMMARY

Ocular mpox is an important clinical feature of systemic mpox virus (MPXV) infection. Heightened clinical suspicion allows for a timely diagnosis and the initiation of antiviral treatment, when appropriate. Randomized clinical trials for mpox systemic and ocular treatment efficacy are lacking. Prior clinical experience with smallpox and in-vitro mpox data support the use of systemic antivirals such as tecovirimat, cidofovir, brincidofovir and topical use of trifluridine in ocular mpox management, though treatment-resistant infection can occur and portend a poor prognosis.

Persistent Monkeypox-Associated Keratouveitis in a Post-LASIK Cornea: A Case Report With Flap Removal

PURPOSE

This study aimed to report a case of persistent keratouveitis associated with mpox virus infection in an immunocompetent patient with a history of laser-assisted in situ keratomileusis (LASIK), leading to the need for flap removal.

METHODS

A comprehensive literature review was conducted, and a detailed case report was presented.

RESULTS

A 44-year-old immunocompetent male patient with a history of LASIK and HIV infection presented with conjunctival and corneal lesions indicative of mpox infection. Despite initial topical treatment, the condition worsened, leading to severe epithelial and stromal keratitis with anterior chamber inflammation. Polymerase chain reaction testing confirmed the presence of mpox virus in conjunctival, corneal, and aqueous humor samples. The patient underwent various treatments, including tecovirimat, oral and topical corticosteroids, and topical trifluridine, and eventually flap removal with amniotic membrane application. Subsequent polymerase chain reaction testing of the aqueous humor yielded negative results, and the cornea gradually reepithelialized without inflammation. After 8 months, the patient's eye remained stable, with a central stromal scar.

CONCLUSIONS

This case highlights the rare occurrence of mpox-associated keratouveitis and emphasizes the challenges faced in its management. The successful outcome achieved through a combination of antiviral therapy, antiinflammatories, and surgical intervention underscores the importance of a multidisciplinary approach in managing such cases.

Corneal Ulcer due to Monkeypox Infection

PURPOSE

To report a rare case of keratitis due to monkeypox infection.

METHODS

A 45-year-old male presented with an epithelial corneal ulcer 20 days following initial diagnosis of monkeypox from genital and perioral lesions. PCR analysis of the epithelium confirmed the presence of human monkeypox virus.

RESULTS

The patient was hospitalized, and ganciclovir gel, as well as povidone iodine 0.6% and moxifloxacin eyedrops were prescribed. Oral tecovirimat 600 mg was administered during 14 days. A therapeutic contact lens was used. Twenty days after the initial diagnosis of keratitis, the corneal defect closed leaving a faint subepithelial haze, and visual acuity was 0.8.

CONCLUSIONS

This is an uncommon case report of epithelial keratitis due to human monkeypox. PCR positivity for monkeypox in the corneal epithelium confirmed the presence of viral material in the cornea.

Monkeypox Infection Causing Conjunctival Vesicles and Anterior Uveitis

Human monkeypox is a zoonosis caused by an orthopoxvirus and the clinical presentation resembles that of smallpox and chickenpox. The disease may start with a prodrome that includes lymphadenopathy, headache, fatigue, and fever, followed by a vesiculo-pustular rash. Ocular manifestations such as conjunctivitis and edema are present in approximately 20% of affected people, with a greater incidence among unvaccinated patients. Corneal involvement has also been reported and can result in corneal scarring and severe forms of keratitis. The natural course of the disease is most often benign and self-limiting, however, in some individuals, especially immunocompromised patients, there is a risk of complications such as bronchopneumonia, encephalitis, and vision loss. Herein, we present a case of a patient with monkeypox which caused conjunctival vesicles and anterior uveitis.

Conjunctival Biopsy of a Patient With Mpox

This case report describes a conjunctival biopsy of a patient with mpox infection.

Mpox in people living with HIV

PURPOSE OF REVIEW

The 2022 global outbreak of mpox disproportionally affected people with HIV (PWH). We review the data on the presentation, treatment, and prevention of mpox in PWH.

RECENT FINDINGS

Most PWH with mpox had a mild and self-limiting illness, no different to people without HIV. A higher rate of rectal symptoms has been reported among PWH and those with advanced HIV disease were at higher risk of severe disease, hospitalization, and death. Treatment with antivirals was widely used in hospitalized patients without any randomized control trial data to support its use and without any data specifically in PWH. Use of smallpox vaccines to prevent mpox is safe in PWH regardless of CD4+ cell count. There is limited data on efficacy in those with lower CD4+ cell count and on long-term protective efficacy.

SUMMARY

PWH should be offered vaccination against mpox in line with national guidelines. PWH should be individually risk-assessed for severe mpox, based on their CD4+ cell count and co-morbidities and ideally recruited into treatment trials to build an evidence base on efficacy. HIV and other sexually transmitted infection testing should be offered to all people diagnosed with mpox.

Ocular involvement secondary to Monkeypox virus infection

We present the case of a 37-year-old male patient with symptoms compatible with adenoviral conjunctivitis of 5 days' evolution. Topical corticosteroids, lubricants and removal of pseudomembranes were prescribed. PCR analysis of conjunctival exudate was positive for Monkeypox virus. During follow-up, the patient developed corneal ulcers with a torpid course, requiring admission for treatment with Tecovirimat. Ocular involvement by Monkeypox virus is usually mild and self-limiting. Cases with severe visual involvement have been described when there is corneal damage, as exemplified in this case. After admission to hospital for systemic treatment, the patient progressed favourably.

Knowledge, Attitudes, and Willingness of Healthcare Workers in Iraq's Kurdistan Region to Vaccinate against Human Monkeypox: A Nationwide Cross-Sectional Study

Although human monkeypox infections had not been recorded in the Kurdistan region of Iraq as of August 2023, the rapid growth of cases worldwide and the detection of monkeypox in neighboring Middle Eastern nations call for careful planning and timely response measures. Educating and empowering frontline healthcare workers (HCWs) so that they can act to curb the spread of monkeypox infections are core elements of primary prevention and protecting public health. Therefore, this study aimed to assess HCWs' knowledge and attitudes about monkeypox and their willingness to vaccinate against monkeypox. By employing a convenience sampling method, an online survey was disseminated via Google Forms between 1 November 2022 and 15 January 2023. The researchers utilized regression analyses to ascertain the factors associated with the three parameters: knowledge, attitude, and the willingness to vaccinate. A total of 637 HCWs were included in the analysis (ages ranged between 21 and 51 years). The mean overall scores were 8.18 of a max score of 16 (SD 3.37), 3.4 of 5 (SD 1.37), and 2.41 of 5 (SD 1.25) for knowledge, attitude, and willingness to vaccinate, respectively. A multivariate logistic regression analysis demonstrated that HCWs who had heard about monkeypox before 2022 rather than later had a higher level of knowledge (AOR: 4.85; 95% CI: 2.81-8.36; p < 0.001). In addition, those who had newly joined the workforce or had less than 1 year experience in practice had more positive attitudes about curbing monkeypox (AOR: 0.35; 95% CI: 0.20-0.59; p < 0.01) than those who practiced for longer. No significant predictors of willingness to vaccinate against monkeypox were identified. The research revealed that HCWs exhibited a relatively low level of monkeypox knowledge. They also had poor attitudes towards monkeypox vaccination and were therefore reluctant to receive the vaccines. Imparting knowledge about the infectious disease can cultivate better awareness and attitudes among HCWs as to their roles in mitigating the spread of an epidemic in the foreseeable future.

Spectrum of ophthalmic manifestations in monkeypox virus infection worldwide: Systematic review and meta-analysis

Mpox virus infection is a significant public health concern worldwide due to its potential severity and the likelihood of outbreaks occurring across different regions. Ophthalmic manifestations of the disease have been linked with more severe cases, leading to the need for hospitalization and antiviral therapy. A systematic review and meta-analysis were conducted following PRISMA guidelines to summarize the literature available on this topic. The review revealed that ophthalmic manifestations, such as conjunctivitis and periocular umbilicated lesions, are the most common in Mpox virus infections. However, severe manifestations, such as corneal opacity, that can potentially cause blindness may also occur. Antiviral treatment with tecovirimat and topical management for conjunctivitis can be considered for severe cases. However, the evidence quality is poor due to the predominance of case reports and imprecise characterization of the ophthalmic manifestations. Overall, ophthalmologists and healthcare professionals should be aware of these manifestations for early diagnosis and timely treatment.

Human MPox (Monkeypox) Virus Membranous Keratoconjunctivitis With Transient Corneal Hypoesthesia and Late Symblepharon Formation: A Novel Case and Clinical Implications

PURPOSE

The aim of this study was to describe a case of corneal involvement as an early manifestation of ocular disease in the 2022 human mpox (monkeypox) virus outbreak.

METHODS

This is a single case report with longitudinal care.

RESULTS

A 47-year-old immunocompetent man presented with viral conjunctivitis before development of skin lesions or systemic symptoms. Subsequently, he developed membranous keratoconjunctivitis and a corneal epithelial defect. Orthopoxvirus-positive polymerase chain reaction test from his ocular surface was positive. The epithelial defect did not heal with conservative treatment but was successfully treated with amniotic membrane transplantation over 8 days. Reduced corneal sensation was noted after epithelial healing, and polymerase chain reaction from the ocular surface remained positive at 17 days from symptom onset, with slowly recovering conjunctivitis at 21 days. Continued membrane formation required repeated removal but significantly improved with topical corticosteroid treatment after epithelial healing by 29 days of symptom onset. Corneal sensation normalized by 87 days from symptom onset at which time symblepharon were noted but PCR testing from the ocular surface was negative.

CONCLUSIONS

Early corneal involvement of human monkeypox virus is possible. Transient corneal hypoesthesia may be due to acute inflammation. Chronic inflammatory changes can result in symblepharon. These findings have potential implications in patient care and corneal donation.

Ophthalmic manifestations of monkeypox infection

After the global COVID-19 pandemic, there has been an alarming concern with the monkeypox (mpox) outbreak, which has affected more than 110 countries worldwide. Monkeypox virus is a doublestranded DNA virus of the genus Orthopox of the Poxviridae family, which causes this zoonotic disease. Recently, the mpox outbreak was declared by the World Health Organization (WHO) as a public health emergency of international concern (PHEIC). Monkeypox patients can present with ophthalmic manifestation and ophthalmologists have a role to play in managing this rare entity. Apart from causing systemic involvement such as skin lesions, respiratory infection and involvement of body fluids, Monkeypox related ophthalmic disease (MPXROD) causes varied ocular manifestations such as lid and adnexal involvement, periorbital and lid lesion, periorbital rash, conjunctivitis, blepharocounctivitis and keratitis. A detailed literature review shows few reports on MPXROD infections with limited overview on management strategies. The current review article is aimed to provide the ophthalmologist with an overview of the disease with a spotlight on ophthalmic features. We briefly discuss the morphology of the MPX, various modes of transmission, an infectious pathway of the virus, and the host immune response. A brief overview of the systemic manifestations and complications has also been elucidated. We especially highlight the detailed ophthalmic manifestations of mpox, their management, and prevention of vision threatening sequelae.

Late ophthalmologic manifestations of monkeypox in a Latin American immunosuppressed patient

BACKGROUND

The re-emergence of Monkeypox (MPX) and its related ophthalmic disease represent a clinical challenge in the initial stages because of the presence of lesions like those caused by varicella zoster, syphilis, and other infections due to other poxviruses. Human Immunodeficiency Virus (HIV) infection and secondary immunodepression raise the risk of severe and prolonged disease.

PURPOSE

We present the case of a young immunosuppressed male patient with MPX, who presented with multiple skin lesions, also including risky ophthalmological manifestations due to extensive eyelid involvement.

CONCLUSIONS

We describe a novel form of late-onset conjunctivitis and eyelid lesions, without active extraocular disease, highlighting the heterogeneous behavior of the new clinical form of MPX, that exhibits a wide spectrum of lesions in different stages of evolution.

Ophthalmic Manifestations of the Monkeypox Virus: A Systematic Review and Meta-Analysis

Background: The accurate estimation of the prevalence of mpox-induced ophthalmic lesions will enable health departments to allocate resources more effectively during the ongoing mpox pandemic. The aim of this meta-analysis was to estimate the global prevalence of ophthalmic manifestations in mpox patients. Methods: A systematic search was carried out in seven databases—Pub Med, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane—for studies published on or before 12 December 2022. The pooled prevalence of ophthalmic manifestations was estimated by the random effects model. Risk of bias assessment of the studies and sub-group analysis to explain heterogeneity were undertaken. Results: Overall, 12 studies were included, with 3239 confirmed mpox cases, among which 755 patients reported ophthalmic manifestations. The pooled prevalence of ophthalmic manifestations was 9% (95% confidence interval (CI), 3–24). Studies from Europe reported a very low prevalence of ocular manifestations of 0.98% (95% CI 0.14–2.31), compared to studies from Africa with a substantially higher prevalence of 27.22% (95% CI 13.69–43.26). Conclusions: A wide variation in the prevalence of ocular manifestations among mpox patients was observed globally. Healthcare workers involved in mpox-endemic African countries should be aware of ocular manifestations for early detection and management.

Severe Corneal Involvement Associated With Mpox Infection

This article discusses 2 cases of severe corneal involvement during mpox.

Ocular presentation of Mpox in a healthy child without known exposure

Ocular complications can occur from Mpox infection and are increasingly being reported, with the rise in worldwide cases. There are few reports of Mpox outside of endemic areas in healthy children. We describe a healthy girl with Mpox who presented with ocular symptoms after experiencing trauma to the eye; this case highlights a pediatric case of Mpox localized to the eye and periorbital region. In the absence of a prodromal phase, the ocular signs and symptoms were initially thought to represent more common, benign etiologies. This case underscores the importance of considering Mpox, even in the absence of known exposures or in the setting of an atypical presentation.

A Review of Monkeypox Ocular Manifestations and Complications: Insights for the 2022 Outbreak

Monkeypox (MPVX) infection has been associated with multiorgan presentations. Thus, monkeypox infection's early and late complications are of particular concern, prompting health systems to decipher threatening sequels and their possible countermeasures. The current article will review the clinical signs and symptoms of the present and former outbreaks, differential diagnoses, workup and treatment of the ocular manifestations of MPXV infection in detail. One of the uncommon yet considerable MPXV complications is ocular involvement. These injuries are classified as (1) more frequent and benign lesions and (2) less common and vision-threatening sequels. Conjunctivitis, blepharitis and photophobia are the most uncomplicated reported presentations. Moreover, MPXV can manifest as eye redness, frontal headache, orbital and peri-ocular rashes, lacrimation and ocular discharge, subconjunctival nodules and, less frequently, as keratitis, corneal ulceration, opacification, perforation and blindness. The ocular manifestations have been less frequent and arguably less severe within the current outbreak. Despite the possibility of underestimation, the emerging evidence from observational investigations documented rates of around 1% for ocular involvement in the current outbreak compared to a 9-23% incidence in previous outbreaks in the endemic countries. The history of smallpox immunization is a protective factor against these complications. Despite a lack of definite and established treatment, simple therapies like regular lubrication and prophylactic use of topical antibiotics may be considered for MPXV ocular complications. Timely administration of specific antivirals may also be effective in severe cases. Monkeypox usually has mild to moderate severity and a self-limited course. However, timely recognition and proper management of the disease could reduce the risk of permanent ocular sequelae and disease morbidity.

Tecovirimat Treatment for Monkeypox Virus Keratouveitis

This case report describes tecovirimat treatment for a patient with monkeypox virus–related keratouveitis.

[Monkeypox: Important facts for the ophthalmologist]

The current monkeypox virus (MPXV) outbreak, raging since May 2022, is the largest ever observed on a world-wide scale. Despite previously being endemic in west and central Africa with a mortality rate of up to 10%, it remained a neglected tropical disease. Along with other recent pandemics gaining much attention, this MPXV outbreak has provided an opportunity to improve our understanding of its physiopathology and better define management strategies, particularly in patients with more serious disease. From the ophthalmologist's perspective, eyelid involvement and conjunctivitis or keratoconjunctivitis are frequently observed and may precede systemic signs or even remain the major site of involvement. While the course of MPXV keratoconjunctivitis is most often favorable, severe cases pose a functional threat, in particular for immunocompromised patients. This review provides an overview of MPXV pathophysiology, diagnosis and treatment, as well as considerations for prevention of transmission. During such an epidemic, the ophthalmologist can be the first to diagnose MPXV, treat the ocular involvement, and set up adequate preventative measures in collaboration with infectious disease specialists.

Ocular MPox: A report of two cases

We report two cases of ocular MPox in men living with HIV, and review the clinical manifestations, diagnosis, and treatment of this rare syndrome. Our cases highlight the need for early recognition and prompt treatment for this potentially sight threatening infection.

Monkeypox Virus and Ophthalmology-A Primer on the 2022 Monkeypox Outbreak and Monkeypox-Related Ophthalmic Disease

Importance

An ongoing global monkeypox virus outbreak in 2022 includes the US and other nonendemic countries. Monkeypox ophthalmic manifestations may present to the ophthalmologist, or the ophthalmologist may be involved in comanagement. This narrative review creates a primer for the ophthalmologist of clinically relevant information regarding monkeypox, its ophthalmic manifestations, and the 2022 outbreak.

Observations

Monkeypox virus is an Orthopoxvirus (genus includes variola [smallpox] and vaccinia [smallpox vaccine]). The 2022 outbreak is of clade II (historically named West African clade), specifically subclade IIb. In addition to historic transmission patterns (skin lesions, bodily fluids, respiratory droplets), sexual transmission has also been theorized in the current outbreak due to disproportionate occurrence in men who have sex with men. Monkeypox causes a characteristic skin eruption and mucosal lesions and may cause ophthalmic disease. Monkeypox-related ophthalmic disease (MPXROD) includes a spectrum of ocular pathologies including eyelid/periorbital skin lesions, blepharoconjunctivitis, and keratitis). Smallpox vaccination may reduce MPXROD occurrence. MPXROD seems to be rarer in the 2022 outbreaks than in historical outbreaks. MPXROD may result in corneal scarring and blindness. Historical management strategies for MPXROD include lubrication and prevention/management of bacterial superinfection in monkeypox keratitis. Case reports and in vitro data for trifluridine suggest a possible role in MPXROD. Tecovirimat, cidofovoir, brincidofovir and vaccinia immune globulin intravenous may be used for systemic infection. There is a theoretical risk for monkeypox transmission by corneal transplantation, and the Eye Bank Association of America has provided guidance. Smallpox vaccines (JYNNEOS [Bavarian Nordic] and ACAM2000 [Emergent Product Development Gaithersburg Inc]) provide immunity against monkeypox.

Conclusions and Relevance

The ophthalmologist may play an important role in the diagnosis and management of monkeypox. MPXROD may be associated with severe ocular and visual morbidity. As the current outbreak evolves, up-to-date guidance from public health organizations and professional societies are critical.

Monkeypox Virus Infections in Humans

Human monkeypox is a viral zoonosis endemic to West and Central Africa that has recently generated increased interest and concern on a global scale as an emerging infectious disease threat in the midst of the slowly relenting COVID-2019 disease pandemic. The hallmark of infection is the development of a flu-like prodrome followed by the appearance of a smallpox-like exanthem. Precipitous person-to-person transmission of the virus among residents of 100 countries where it is nonendemic has motivated the immediate and widespread implementation of public health countermeasures. In this review, we discuss the origins and virology of monkeypox virus, its link with smallpox eradication, its record of causing outbreaks of human disease in regions where it is endemic in wildlife, its association with outbreaks in areas where it is nonendemic, the clinical manifestations of disease, laboratory diagnostic methods, case management, public health interventions, and future directions.