Anti-Vaccinia Immunoglobulin and Post-exposure Prophylaxis with Vaccinia-based Vaccine for Management of the Monkeypox Outbreak

Clinical, histopathologic, immunohistochemical, and electron microscopic findings in cutaneous monkeypox: A multicenter retrospective case series in Spain

BACKGROUND

The worldwide outbreak of monkeypox has evidenced the usefulness of the dermatologic manifestations for its diagnosis.

OBJECTIVE

To describe the histopathologic and immunohistochemical findings of monkeypox cutaneous lesions.

METHODS

This is a retrospective histopathologic and immunohistochemical study of 20 patients with positive Monkeypox virus DNA polymerase chain reaction and immunohistochemical positivity for Vaccinia virus in cutaneous lesions. Four cases were also examined by electron microscopy.

RESULTS

The most characteristic histopathologic findings consisted of full-thickness epidermal necrosis with hyperplasia and keratinocytic ballooning at the edges. In some cases, the outer root sheath of the hair follicle and the sebaceous gland epithelium were affected. Intraepithelial cytoplasmic inclusion bodies and scattered multinucleated keratinocytes were occasionally found. Immunohistochemically, strong positivity with anti-Vaccinia virus antibody was seen in the cytoplasm of ballooned keratinocytes. Electron microscopy study demonstrated numerous viral particles of monkeypox in affected keratinocytes.

LIMITATIONS

Small sample size. Electron microscopic study was only performed in 4 cases.

CONCLUSION

Epidermal necrosis and keratinocytic ballooning are the most constant histopathologic findings. Immunohistochemical positivity for Vaccinia virus was mostly detected in the cytoplasm of the ballooned keratinocytes. These findings support the usefulness of histopathologic and immunohistochemical studies of cutaneous lesions for diagnosis of monkeypox.