The pathophysiological and immunological background of the monkeypox virus infection: An update

Repurposing doxycycline for the inhibition of monkeypox virus DNA polymerase: a comprehensive computational study

The global spread of monkeypox, caused by the double-stranded DNA monkeypox virus (MPXV), has underscored the urgent need for effective antiviral treatments. In this study, we aim to identify a potent inhibitor for MPXV DNA polymerase (DNAP), a critical enzyme in the virus replication process. Using a computational drug repurposing approach, we performed a virtual screening of 1615 FDA-approved drugs based on drug-likeness and molecular docking against DNAP. Among these, 1430 compounds met Lipinski's rule of five for drug-likeness, with Doxycycline emerging as the most promising competitive inhibitor, binding strongly to the DNAP active site with a binding affinity of - 9.3 kcal/mol. This interaction involved significant hydrogen bonds, electrostatic interactions, and hydrophobic contacts, with Doxycycline demonstrating a stronger affinity than established antivirals for smallpox, including Cidofovir, Brincidofovir, and Tecovirimat. Stability and flexibility analyses through a 200 ns molecular dynamics simulation and normal mode analysis confirmed the robustness of Doxycycline binding to DNAP. Overall, our results suggest Doxycycline as a promising candidate for monkeypox treatment, though additional experimental and clinical studies are needed to confirm its therapeutic potential and clinical utility.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40203-025-00307-7.

Bioactive Deep Eutectic Solvent-Involved Sprayable Versatile Hydrogel for Monkeypox Virus Lesions Treatment

To address the issues of infectious virus, bacterial secondary infections, skin pigmentation, and scarring caused by monkeypox virus (MPXV), a sprayable hydrogel with versatile functions was developed with comprehensive properties. Based on current research, the bioactive deep eutectic solvent (DES) of rosmarinic acid-proanthocyanidin-glycol (RPG) was designed and synthesized as active agent, and molecular docking was applied to discover its binding to MPXV proteins through H-bonds and van der Waals interactions, and the docking results show the binding energies between RA, PC, Gly and MPXV proteins are -58.7188, -50.2311, and -18.4755 kcal/mol, respectively. Additionally, poly(vinyl alcohol) (PVA), borate, and xylitol (Xyl) were integrated with RPG to prepare the PB-RPG-Xyl hydrogel, which was characterized by popular ways. The pH-responsive properties of the hydrogel accelerated the release of RPG under acidic conditions, resulting in an increased cumulative release percentage of 84.83% at pH 5.5 at 210 min. Besides that, it was proved to have the expected sprayability, self-healing, adhesion, and shape-adaptability. The results of molecular dynamic simulation were meaningful to understanding its formation and self-healing mechanisms. Furthermore, the hydrogel shows ideal degradability, removability, and biocompatibility. Lastly, its multiple functions were systematically explored, including UV-blocking, blood clotting, cooling, antioxidant, antibacterial, and virus inhibition properties. The developed sprayable PB-RPG-Xyl hydrogel represents the first promising dressing based on natural bioactive DES for MPXV lesions management, which not only expands the application of green solvents in health care but also provides a convenient and effective treatment process for MPXV infection in the face of difficult skin lesions and complex treatment needs.

Inhibition of Monkeypox Virus DNA Polymerase Using Moringa oleifera Phytochemicals: Computational Studies of Drug-Likeness, Molecular Docking, Molecular Dynamics Simulation and Density Functional Theory

The emergence of zoonotic monkeypox (MPX) disease, caused by the double-stranded DNA monkeypox virus (MPXV), has become a global threat. Due to unavailability of a specific small molecule drug for MPX, this study investigated Moringa oleifera phytochemicals to find potent and safe inhibitors of DNA Polymerase (DNA Pol), a poxvirus drug target due to its role in the viral life cycle. For that, 146 phytochemicals were screened through drug-likeness and molecular docking analyses. Among these, 136 compounds exhibited drug-like properties, with Gossypetin showing the highest binding affinity (- 7.8 kcal/mol), followed by Riboflavin (- 7.6 kcal/mol) and Ellagic acid (- 7.6 kcal/mol). In comparison, the control drugs Cidofovir and Brincidofovir displayed lower binding affinities, with binding energies of - 6.0 kcal/mol and - 5.1 kcal/mol, respectively. Hydrogen bonds, electrostatic and hydrophobic interactions were the main non-bond interactions between inhibitors and protein active site. The identified compounds were further evaluated using molecular dynamics simulation, density functional theory analysis and ADMET analysis. Molecular dynamics simulations conducted over 200 ns revealed that DNA Pol-Gossypetin complex was not stable, however, Riboflavin and Ellagic acid complexes showed excellent stability indicating them as better DNA Pol inhibitors. The density functional theory analysis exhibited the chemical reactivity of these inhibitor compounds. The ADMET analysis suggested that the top phytochemicals were safe and showed no toxicity. In conclusion, this study has identified Riboflavin and Ellagic acid as potential DNA Pol inhibitors to control MPXV. Further experimental assays and clinical trials are needed to confirm their activity against the disease.

Graphical Abstract

Targeting Monkeypox Virus Methyltransferase: Virtual Screening of Natural Compounds from Middle-Eastern Medicinal Plants

Monkeypox is an infectious disease resulting from the monkeypox virus, and its fatality rate varies depending on the virus clade and the location of the outbreak. In monkeypox virus, methyltransferase (MTase) plays a crucial role in modifying the cap structure of viral mRNA. This alteration assists the virus in evading the host's immune system, enhances viral protein synthesis, and ultimately enables successful infection and replication within host cells. Given the significance of MTase in viral infection and spread within the host, our study aimed to identify a natural inhibitor for this enzyme using docking and molecular dynamic (MD) simulations. We collected a total of 12,971 natural compounds from 200 medicinal plants in the Middle East. After eliminating duplicate compounds, we had 5,749 unique ligand conformers, which we then subjected to high-throughput virtual screening against MTase. The most promising hits were further evaluated using the extra-precision (XP) tool. The affinity of these hits was also assessed by Prime-Molecular Mechanics/Generalized Born Surface Area (MMGBSA) tool. The analysis revealed that two standard controls (sinefungin and TO1119) and two Middle-Eastern compounds (folic acid and 1,2,4,6-tetragalloylglucose) exhibited the best XP docking scores. According to Prime MMGBSA calculations, the Middle-Eastern compounds showed higher affinities, with values of - 60.61 kcal/mol for 1,2,4,6-tetragalloylglucose and - 51.87 kcal/mol for folic acid, surpassing the controls (TO1119 at - 35.71 kcal/mol and sinefungin at - 31.51 kcal/mol). In the majority of Molecular dynamic (MD) simulations, folic acid exhibited demonstrated greater stability than sinefungin. Further investigation revealed that folic acid occupied a critical position in the active site of MTase, which reduced its interaction with the mRNA substrate. Based on these findings, it can be concluded that folic acid is a highly promising natural compound for potential use in the cost-effective treatment of monkeypox virus. The identification of folic acid as a potential antiviral agent highlights the importance of nature in providing new therapeutic uses that have significant implications for global health, particularly in regions where monkeypox viral outbreaks are prevalent. However, it is essential to note that further wet-lab validations are necessary to confirm its efficacy for treatment in a medical context.

A Systematic Review on the Mental Health Status of Patients Infected With Monkeypox Virus

Objectives

This study aims to extract and summarize the literature on the mental health status of patients with monkeypox.

Methods

This review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using different databases and publishers such as Scopus, Sage, ScienceDirect, PubMed, BMJ, Wiley Online Library, Wolters Kluwer OVID-SP, and Google Scholar. The literature review was based on monkeypox and mental health. The year of publication was 2021-2023, during the monkeypox disease period. Data were extracted from opinions, editorials, empirical studies, and surveys.

Results

Based on the literature related to the mental status of patients with monkeypox, the following themes and subthemes were identified: anxiety and depression, self-harm and suicidal tendencies, neuropsychiatric symptoms, mental health, social stigma, sex workers, vaccination, and stress-related diseases.

Conclusion

A review of monkeypox virus infection studies reveals that 25%-50% of patients experience anxiety and depression due to isolation, boredom, and loneliness. Factors such as infected people, a lack of competence among healthcare professionals, and shame over physical symptoms exacerbate mental insults. The implications of society include increased self-harm, suicide, low productivity, fear of stigmatization, and transmission of infection.

Monkeypox Virus (MPXV) Infection: A Review

Monkeypox is a viral disease; its outbreak was recently declared a global emergency by the World Health Organization. For the first time, a monkeypox virus (MPXV)-infected patient was found in India. Various researchers back-to-back tried to find the solution to this health emergency just after COVID-19. In this review, we discuss the current outbreak status of India, its transmission, virulence factors, symptoms, treatment, and the preventive guidelines generated by the Indian Health Ministry. We found that monkeypox virus (MPXV) disease is different from smallpox, and the age group between 30-40 years old is more prone to MPXV disease. We also found that, besides homosexuals, gays, bisexuals, and non-vegetarians, it also affects normal straight men and women who have no history of travel. Close contact should be avoided from rats, monkeys and sick people who are affected by monkeypox. To date, there are no monkeypox drugs, but Tecovirimat is more effective than other drugs that are used for other viral diseases like smallpox. Therefore, we need to develop an effective antiviral agent against the virulence factor of MXPV.

Comparative Epidemiological Assessment of Monkeypox Infections on a Global and Continental Scale Using Logistic and Gompertz Mathematical Models

The monkeypox virus (MPXV) has caused an unusual epidemiological scenario-an epidemic within a pandemic (COVID-19). Despite the inherent evolutionary and adaptive capacity of poxviruses, one of the potential triggers for the emergence of this epidemic was the change in the status of orthopoxvirus vaccination and eradication programs. This epidemic outbreak of HMPX spread worldwide, with a notable frequency in Europe, North America, and South America. Due to these particularities, the objective of the present study was to assess and compare cases of HMPX in these geographical regions through logistic and Gompertz mathematical modeling over one year since its inception. We estimated the highest contagion rates (people per day) of 690, 230, 278, and 206 for the world, Europe, North America, and South America, respectively, in the logistic model. The equivalent values for the Gompertz model were 696, 268, 308, and 202 for the highest contagion rates. The Kruskal-Wallis Test indicated different means among the geographical regions affected by HMPX regarding case velocity, and the Wilcoxon pairwise test indicated the absence of significant differences between the case velocity means between Europe and South America. The coefficient of determination (R2) values in the logistic model varied from 0.8720 to 0.9023, and in the Gompertz model, they ranged from 0.9881 to 0.9988, indicating a better fit to the actual data when using the Gompertz model. The estimated basic reproduction numbers (R0) were more consistent in the logistic model, varying from 1.71 to 1.94 in the graphical method and from 1.75 to 1.95 in the analytical method. The comparative assessment of these mathematical modeling approaches permitted the establishment of the Gompertz model as the better-fitting model for the data and the logistic model for the R0. However, both models successfully represented the actual HMPX case data. The present study estimated relevant epidemiological data to understand better the geographic similarities and differences in the dynamics of HMPX.

Exploring the key genomic variation in monkeypox virus during the 2022 outbreak

BACKGROUND

In 2022, a global outbreak of monkeypox occurred with a significant shift in its epidemiological characteristics. The monkeypox virus (MPXV) belongs to the B.1 lineage, and its genomic variations that were linked to the outbreak were investigated in this study. Previous studies have suggested that viral genomic variation plays a crucial role in the pathogenicity and transmissibility of viruses. Therefore, understanding the genomic variation of MPXV is crucial for controlling future outbreaks.

METHODS

This study employed bioinformatics and phylogenetic approaches to evaluate the key genomic variation in the B.1 lineage of MPXV. A total of 979 MPXV strains were screened, and 212 representative strains were analyzed to identify specific substitutions in the viral genome. Reference sequences were constructed for each of the 10 lineages based on the most common nucleotide at each site. A total of 49 substitutions were identified, with 23 non-synonymous substitutions. Class I variants, which had significant effects on protein conformation likely to affect viral characteristics, were classified among the non-synonymous substitutions.

RESULTS

The phylogenetic analysis revealed 10 relatively monophyletic branches. The study identified 49 substitutions specific to the B.1 lineage, with 23 non-synonymous substitutions that were classified into Class I, II, and III variants. The Class I variants were likely responsible for the observed changes in the characteristics of circulating MPXV in 2022. These key mutations, particularly Class I variants, played a crucial role in the pathogenicity and transmissibility of MPXV.

CONCLUSION

This study provides an understanding of the genomic variation of MPXV in the B.1 lineage linked to the recent outbreak of monkeypox. The identification of key mutations, particularly Class I variants, sheds light on the molecular mechanisms underlying the observed changes in the characteristics of circulating MPXV. Further studies can focus on functional domains affected by these mutations, enabling the development of effective control strategies against future monkeypox outbreaks.

Cross-reactive antibody response to Monkeypox virus surface proteins in a small proportion of individuals with and without Chinese smallpox vaccination history

BACKGROUND

After the eradication of smallpox in China in 1979, vaccination with the vaccinia virus (VACV) Tiantan strain for the general population was stopped in 1980. As the monkeypox virus (MPXV) is rapidly spreading in the world, we would like to investigate whether the individuals with historic VACV Tiantan strain vaccination, even after more than 40 years, could still provide ELISA reactivity and neutralizing protection; and whether the unvaccinated individuals have no antibody reactivity against MPXV at all.

RESULTS

We established serologic ELISA to measure the serum anti-MPXV titer by using immunodominant MPXV surface proteins, A35R, B6R, A29L, and M1R. A small proportion of individuals (born before 1980) with historic VACV Tiantan strain vaccination exhibited serum ELISA cross-reactivity against these MPXV surface proteins. Consistently, these donors also showed ELISA seropositivity and serum neutralization against VACV Tiantan strain. However, surprisingly, some unvaccinated young adults (born after 1980) also showed potent serum ELISA activity against MPXV proteins, possibly due to their past infection by some self-limiting Orthopoxvirus (OPXV).

CONCLUSIONS

We report the serum ELISA cross-reactivity against MPXV surface protein in a small proportion of individuals both with and without VACV Tiantan strain vaccination history. Combined with our serum neutralization assay against VACV and the recent literature about mice vaccinated with VACV Tiantan strain, our study confirmed the anti-MPXV cross-reactivity and cross-neutralization of smallpox vaccine using VACV Tiantan strain. Therefore, it is necessary to restart the smallpox vaccination program in high risk populations.

Differences in pathogenicity among the mpox virus clades: impact on drug discovery and vaccine development

Since May 2022, mpox virus (MPXV) has attracted considerable attention due to a multi-country outbreak. Marked differences in epidemiology, transmission, and pathology between the 2022 global mpox outbreak (clade IIb) and classical mpox disease, endemic in Africa (clades I and IIa) have been highlighted. MPXV genome analysis has identified the genomic changes characterizing clade IIb and the drivers of MPXV rapid evolution. Although mpox cases have largely declined, MPXV cryptic transmission and microevolution continues, which may lead to an MPXV of unpredictable pathogenicity. Vaccines and antivirals developed against variola virus, the agent that caused the extinguished plague smallpox, have been used to contain the 2022 mpox outbreak. In this review article, recent findings on MPXV origin and evolution and relevant models able to recapitulate differences in MPXV pathogenicity, which are important for drug and vaccine development, are discussed.

Recent Outbreak of Monkeypox: Implications for Public Health Recommendations and Crisis Management in India

Monkeypox is a rare and self-limiting disease that was eradicated globally through vaccination approximately forty years ago, following the eradication of smallpox. The purpose of this article is to explore the implications of the recent monkeypox outbreak on public health recommendations and crisis management in India. An overview of the consequences of the current monkeypox epidemic on public health, epidemiology, clinical findings, management, challenges, and existing strategies for this disease, along with recommendations are discussed. It is crucial to develop evidence-based recommendations for the diagnosis and treatment of monkeypox, as well as early case identification and contact tracing. To prevent the spread of infection, travelers from affected countries should be subjected to health testing and quarantine. In order to successfully control the outbreak, a multidisciplinary team should be established to manage the monkeypox virus at tertiary care facilities, and health workers with occupational exposure to the virus should be assessed and given management plans.

The Emergence of Mpox: Epidemiology and Current Therapeutic Options

The world recently witnessed the emergence of new epidemic outbreaks like COVID-19 and mpox. The 2022 outbreak of mpox amid COVID-19 presents an intricate situation and requires strategies to combat the status quo. Some of the challenges to controlling an epidemic include present knowledge of the disease, available treatment options, appropriate health infrastructures facilities, current scientific methods, operations concepts, availability of technical staff, financial funds, and lastly international policies to control an epidemic state. These insufficiencies often hinder the control of disease spread and jeopardize the health of countless people. Also, disease outbreaks often put a huge burden on the developing economies. These countries are the worst affected and are immensely dependent on assistance provided from the larger economies to control such outbreaks. The first case of mpox was reported in the 1970s and several outbreaks were detected thereafter in the endemic areas eventually leading to the recent outbreak. Approximately, more than 80,000 individuals were infected, and 110 countries were affected by this outbreak. Yet, no definite vaccines and drugs are available to date. The lack of human clinical trials affected thousands of individuals in availing definite disease management. This paper focuses on the epidemiology of mpox, scientific concepts, and treatment options including future treatment modalities for mpox.

Human Monkeypox Experience in a Tertiary Level Hospital in Milan, Italy, between May and October 2022: Epidemiological Features and Clinical Characteristics

Background: Monkeypox virus (mpxv) started to spread to Europe and North America at the beginning of the current outbreak in May 2022, and the World Health Organization (WHO) declared Human Monkeypox (mpox) as a public health emergency of international concern (PHEIC) in July 2022. The aim of this observational analysis is to describe demographical data, symptoms presentation and clinical course till outcome of individuals diagnosed with mpox, between May and October 2022, at our open-access Sexual Health Clinic in IRCCS San Raffaele Hospital in Milan, Italy. Methods: Among people who accessed our Sexual Health Clinic, we considered, as suspected diagnosis of mpox, individuals with consistent symptoms and epidemiological criteria. Following the physical examination, oropharyngeal, anal, genital and cutaneous swabs, plus plasma, urine and seminal fluid were collected as biological materials to detect mpxv DNA. We also performed a screening for sexually transmitted infections (STIs). Results: Overall, 140 individuals with mpox were included in this study. Median age was 37 (interquartile, IQR 33, 43) years old. Males were 137 (98%) and men who have sex with men (MSM) were 134 (96%). As risk factors, we detected travels abroad in 35 (25%) individuals and close contact with mpox cases in 49 (35%). There were 66 (47%) people living with HIV (PLWH). Most frequent symptoms were fever (59%), lymphadenopathy (57%), cutaneous (77%), genital (42%), anal (34%) and oral (26%) lesions, proctitis (39%), sore throat (22%) and generalized rash (5%). At mpox diagnosis, we also observed N. gonorrhoeae in 18 (13%) cases, syphilis in 14 (10%) and C. trachomatis in 12 (9%). Two (1%) people received a concomitant diagnosis of HIV infection. We attended to 21 (15%) complications, with nine (6%) cases of hospitalization including six (IQR 3,7) median hospital days. Forty-five (32%) patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs), 37 (26%) with antibiotics and eight (6%) with antiviral drugs. Conclusions: Similarly to other international cohorts, sexual transmission was most frequently present, and concomitant STIs were common. Symptoms were heterogenous, self-resolving and responsive to therapy. Hospitalization was necessary in few patients. There is uncertainty about the future development of mpox and further studies (e.g., potential disease reservoirs, other possible means of transmission, predictors of severe disease) are still needed.

Rapid detection of monkeypox virus by multiple cross displacement amplification combined with nanoparticle-based biosensor platform

The current outbreak of monkeypox virus (MPXV) has become a public health emergency of international concern that highlights the need for rapid, sensitive MPXV diagnostic assays. Here, we combined isothermal multiple cross displacement amplification (MCDA) with nanoparticle-based lateral flow biosensor (LFB) to devise a diagnostic test for the diagnosis of MPXV infection (called MPXV-MCDA-LFB) and differentiation of West and Central African MPXV isolates. The MPXV-MCDA-LFB protocol conducts isothermal MCDA reaction for DNA templates followed by LFB detection of preamplification target sequences. Two MCDA primer sets were designed targeting the D41L and ATI genes of Central and West African MPXV isolates, respectively, and the optimal condition of two MCDA reactions was 64°C for 30 min. The two MCDA reactions were decoded by LFB, which was devised for detecting three targets, including two amplicons yielded from two MCDA reactions and a chromatography control. Thus, the MPXV-MCDA-LFB assay could be completed within 50 min including rapid template preparation (15 min), MCDA reaction (30 min) and reporting of result (<5 min). The MPXV-MCDA-LFB method is very sensitive and can detect the target genes (D14L and ATI) with as low as five copies of plasmid template per reaction and 12.5 copies of pseudotyped virus in human blood samples. The MPXV-MCDA-LFB assay does not cross-react with non-MPXV templates, validating its specificity. Therefore, the MPXV-MCDA-LFB assay developed here is a useful tool for rapid and reliable diagnosis of MPXV infection.

Monkeypox Infection 2022: An Updated Narrative Review Focusing on the Neonatal and Pediatric Population

Monkeypox disease has been endemic in sub-Saharan Africa for decades, attracting remarkable attention only i23n 2022 through the occurrence of a multi-country outbreak. The latter has raised serious public health concerns and is considered a public health emergency by the World Health Organization. Although the disease is usually self-limiting, it can cause severe illness in individuals with compromised immune systems, in children, and/or the pregnant woman-fetus dyad. Patients generally present with fever, lymphadenopathy, and a vesicular rash suggestive of mild smallpox. Serious eye, lung and brain complications, and sepsis can occur. However, cases with subtler clinical presentations have been reported in the recent outbreak. A supportive care system is usually sufficient; otherwise, treatment options are needed in patients who are immunocompromised or with comorbidities. A replication-deficient modified and a live infectious vaccinia virus vaccine can be used both before and after exposure. Due to the persistent spread of monkeypox, it is necessary to focus on the pediatric population, pregnant women, and newborns, who represent fragile contagion groups. Here we assess and summarize the available up-to-date information, focusing on available therapeutic options, with insights into social and school management, breastfeeding, and prevention that will be useful for the scientific community and in particular neonatal and pediatric health professionals.