Monkeypox: A focused narrative review for emergency medicine clinicians

The role of viruses in oral mucosal lesions

The mucosa of the oral cavity is exposed to a large number of different microorganisms such as archaea, bacteria, fungi, parasites, and viruses. Among those, viruses cause specific infections, which can easily be transmitted from one person to another. The infectious route may not only include patients and their relatives but also the dental professional team. Thus, a wide knowledge regarding specific viral infections is crucial for the daily routine. Signs and symptoms of oral viral infections can be completely absent or develop into a pronounced clinical picture, so that early detection and information determine the further course of the infection and its influence on other inflammatory diseases, such as periodontitis, as well as the safety of family members and the social environment. As the clinical manifestation of viral infections may be highly variable leading to heterogenous mucosal lesions it is, in most cases, mandatory to differentiate them by specific microbiological tests in addition to clinical examination procedures. This article will give an overview of the role of viruses infecting the oral mucosa, and in addition, describe their clinical manifestation and management.

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.

Monkeypox Virus Immune Evasion and Eye Manifestation: Beyond Eyelid Implications

Monkeypox virus (MPXV), belonging to the Poxviridae family and Orthopoxvirus genus, is closely related to the smallpox virus. Initial prodromal symptoms typically include headache, fever, and lymphadenopathy. This review aims to detail various ocular manifestations and immune evasion associated with the monkeypox viral infection and its complications, making it appropriate as a narrative review. Common external ocular manifestations of MPXV typically involve a generalized pustular rash, keratitis, discharges, and dried secretions related to conjunctival pustules, photophobia, and lacrimation. Orthopoxviruses can evade host immune responses by secreting proteins that antagonize the functions of host IFNγ, CC and CXC chemokines, IL-1β, and the complement system. One of the most important transcription factors downstream of pattern recognition receptors binding is IRF3, which controls the expression of the crucial antiviral molecules IFNα and IFNβ. We strongly recommend that ophthalmologists include MPXV as part of their differential diagnosis when they encounter similar cases presenting with ophthalmic manifestations such as conjunctivitis, blepharitis, or corneal lesions. Furthermore, because non-vaccinated individuals are more likely to exhibit these symptoms, it is recommended that healthcare administrators prioritize smallpox vaccination for at-risk groups, including very young children, pregnant women, older adults, and immunocompromised individuals, especially those in close contact with MPXV cases.

Monkeypox in humans: Transmission, pathophysiology, diagnosis, treatment, prevention, and all recent updates

The Centers for Disease Control and Prevention (CDC) is monitoring an epidemic of monkeypox infection in the United States. The outbreak is now global and more than 6900 cases have already been reported. There are 83 confirmed cases among children and adolescents, as shown in the report published on November 3, 2022, in the USA. However, monkeypox in pediatric patients is still infrequent (< 0.3% of total cases). Among cases in the United States, 16 cases were in children < 5 years, 12 in the age group 5-12 years, and 55 cases in adolescents 13-17 years old. In the adolescent age group, 89% were male. For children < 12 years of age, close physical contact with an adult household with monkeypox was the primary exposure, but for adolescents, male-to-male sexual contact was found more frequently. The CDC advised United States healthcare providers to remain vigilant for patients with a rash resembling monkeypox, even if there is no history of travel to a country with high risk. This article summarizes the history and epidemiology of monkeypox with a specific emphasis on clinical features and management in pediatric patients.

Mpox

ABSTRACT

Human mpox (formerly known as monkeypox) is a zoonotic disease that causes a smallpox-like infection in humans. The mpox virus, the causative agent of mpox, was first reported to cause human disease in a 9-month-old infant in the Democratic Republic of the Congo in 1970. Since that time, periodic outbreaks in primarily endemic regions have occurred, typically secondary to transmission from wildlife reservoirs. However, in May 2022, after a rapid rise in worldwide cases in largely nonendemic countries, the World Health Organization declared mpox a Public Health Emergency of International Concern. As of January 2022, more than 80,000 cases of mpox in nonendemic countries have occurred, and more than 25,000 cases in the United States alone. Most of these cases occurred in adults, with the highest frequency among men who had sex with men. Children and adolescents represented only 0.3% of US cases as of September 2022, with most infections in young children the result of direct contact with an infected household member. Although infection remains uncommon in US children and teens, pediatric emergency and urgent care providers should be aware of the clinical features, treatment, and prophylaxis of this important emerging infectious disease.

Clinical Strategies and Therapeutics for Human Monkeypox Virus: A Revised Perspective on Recent Outbreaks

An enveloped double-stranded DNA monkeypox virus (MPXV) is a causative agent of the zoonotic viral disease, human monkeypox (HMPX). MPXV belongs to the genus Orthopoxviridae, a family of notorious smallpox viruses, and so it shares similar clinical pathophysiological features. The recent multicountry HMPX outbreak (May 2022 onwards) is recognized as an emerging global public health emergency by the World Health Organization, shunting its endemic status as opined over the past few decades. Re-emergence of HMPX raises concern to reassess the present clinical strategy and therapeutics as its outbreak evolves further. Keeping a check on these developments, here we provide insights into the HMPX epidemiology, pathophysiology, and clinical representation. Weighing on its early prevention, we reviewed the strategies that are being enrolled for HMPX diagnosis. In the line of expanded MPXV prevalence, we further reviewed its clinical management and the diverse employed preventive/therapeutic strategies, including vaccines (JYNNEOS, ACAM2000, VIGIV) and antiviral drugs/inhibitors (Tecovirimat, Cidofovir, Brincidofovir). Taken together, with a revised perspective of HMPX re-emergence, the present report summarizes new knowledge on its prevalence, pathology, and prevention strategies.

A Case of Mistaken Identity: Varicella Zoster and Monkeypox

Mpox, previously referred to as monkeypox, is a zoonotic virus originally endemic to West Africa which has recently garnered significant attention due to a global outbreak. It remains a challenging diagnosis due to varying clinical presentations and similarities with other infectious pathogens. While diligent monitoring of its prevalence remains crucial, clinicians should combat recency bias when forming differentials for viral illnesses with similar presentations. Here, we discuss the case of an immigrant child with self-reported vaccination history of Varicella Zoster who was diagnosed with Mpox in the emergency department but was subsequently found to have Varicella Zoster after further testing. To effectively manage outbreaks and provide optimal care, healthcare professionals should stay up to date on the latest advancements in diagnostic techniques and available interventions.

Addressing vaccine-preventable encephalitis in vulnerable populations

PURPOSE OF REVIEW

Vaccinations have been pivotal in lowering the global disease burden of vaccine-preventable encephalitides, including Japanese encephalitis, tick-borne encephalitis, measles encephalitis, and rabies encephalitis, among others.

RECENT FINDINGS

Populations vulnerable to vaccine-preventable infections that may lead to encephalitis include those living in endemic and rural areas, military members, migrants, refugees, international travelers, younger and older persons, pregnant women, the immunocompromised, outdoor, healthcare and laboratory workers, and the homeless. There is scope for improving the availability and distribution of vaccinations, vaccine equity, surveillance of vaccine-preventable encephalitides, and public education and information.

SUMMARY

Addressing these gaps in vaccination strategies will allow for improved vaccination coverage and lead to better health outcomes for those most at risk for vaccine-preventable encephalitis.

Mimics of Monkeypox: Considerations for the emergency medicine clinician

INTRODUCTION

Mpox, formerly known as monkeypox, is a public health emergency most commonly presenting with a painful rash and several systemic findings. However, there are several conditions that may mimic its presentation.

OBJECTIVE

This narrative review provides a focused overview of mpox mimics for emergency clinicians.

DISCUSSION

Mpox is a global health emergency. The disease is primarily spread through contact, followed by the development of a centrifugally-spread rash that evolves from macules to papules to vesicles to pustules. This is often associated with lymphadenopathy and fever. As the rash is one of the most common presenting signs of the infection, patients mpox may present to the emergency department (ED) for further evaluation. There are a variety of mimics of mpox, including smallpox, varicella, primary and secondary syphilis, acute retroviral syndrome, and genital herpes simplex virus.

CONCLUSION

Knowledge of mpox and its mimics is vital for emergency clinicians to differentiate these conditions and ensure appropriate diagnosis and management.

Stigmatizing Monkeypox and COVID-19: A Comparative Framing Study of The Washington Post's Online News

BACKGROUND

Stigma relating to health can result in a broad range of vulnerabilities and risks for patients and healthcare providers. The media play a role in people's understanding of health, and stigma is socially constructed through many communication channels, including media framing. Recent health issues affected by stigma include monkeypox and COVID-19.

OBJECTIVES

This research aimed to examine how The Washington Post (WP) framed the stigma around monkeypox and COVID-19. Guided by framing theory and stigma theory, online news coverage of monkeypox and COVID-19 was analyzed to understand the construction of social stigma through media frames.

METHODS

This research used qualitative content analysis to compare news framings in The Washington Post's online news coverage of monkeypox and COVID-19.

RESULTS

Using endemic, reassurance, and sexual-transmission frames, The Washington Post predominantly defined Africa as the source of monkeypox outbreaks, indirectly labeled gays as a specific group more likely to be infected with monkeypox, and emphasized that there was no need to worry about the spread of the monkeypox virus. In its COVID-19 coverage, The Washington Post adopted endemic and panic frames to describe China as the source of the coronavirus and to construct an image of panic regarding the spread of the virus.

CONCLUSIONS

These stigma discourses are essentially manifestations of racism, xenophobia, and sexism in public health issues. This research confirms that the media reinforces the stigma phenomenon in relation to health through framing and provides suggestions for the media to mitigate this issue from a framing perspective.

Monkeypox: A current emergency global health threat

Monkeypox (MPXV) is an emerging zoonotic disease carrying a global health threat. Using a multi-disciplinary approach, we review the current MPXV virus infection outbreak including virology, prevention, clinical presentation, and disaster management. MPXV is caused by a double-stranded deoxyribonucleic acid virus. Despite its clinical similarities with smallpox, it is less severe with low mortality. Human-to-human transmission occurs through prolonged direct or close contact, or through blood, body fluids, or mucosal lesions. Risk groups include frontline health workers who care for MPXV patients, household members of an infected patient, and men who have sex with men. Skin lesions are usually, but not always, at the same stage. They may affect the face followed by the distal extremities with fewer lesions on the trunk (centrifugal distribution). Lesions may involve the mouth, genitalia, conjunctiva, and rectum. The majority of cases are mild. Nevertheless, the disease may have long-term effects on the skin, the neurological system, and the eye. Vaccination against MPXV is available but meanwhile should be limited to those who are at high risk. Those vaccinated against smallpox (usually older than 40 years) might be immune against MPXV. Infectious diseases are without borders. If proper action is not taken, there is considerable risk that MPXV will be entrenched worldwide. Our world has a delicate balance between animals, environment, and humans reflecting the need for a "one globe, one health approach" to address this risk. Following the principles of disaster management and using the lessons we have learned from the COVID-19 pandemic will reduce the impact of the MPXV outbreak.

Recent Advances in the Prevention and Management of Monkeypox Viral Infection in Humans

BACKGROUND

There have been several neglected infectious pathogens that have reemerged in the last few decades, including the monkeypox virus, a virus from the orthopoxviral genus that causes monkeypox and is transmitted between animals and humans. The human monkeypox outbreak has spread to several different countries. Because of the outbreak's unusually high case count and lack of connections to endemic nations, there are concerns that the monkeypox transmission pattern may have changed.

OBJECTIVE

The current study aimed to provide recent advancements in the prevention and management of the monkeypox virus in humans.

METHODOLOGY

We have highlighted recent advancements in the prevention and management of the monkeypox virus in humans in this work.

RESULTS

For the treatment and prevention of monkeypox, new medications and vaccinations are being used, and more study is needed to understand the epidemiology, biology, and ecology of the virus in endemic regions and stop future global outbreaks. Vaccines available in the market for the treatment of viruses are JYNEOS and ACAM2000. Some of the antiviral drugs, such as tecovirimat, brincidofovir, cidofovir, trifluridine, and vaccinia immune globulin, are used for the treatment of the monkeypox virus. Some of the vaccines, such as NIOCH-14, Cidofovir, CMX-001, and ST-246, are currently in clinical trials.

CONCLUSION

We have, herein, covered features of monkeypox viral biology that are important for risk assessment and getting ready for an outbreak of the monkeypox virus, with a focus on recent advances in knowledge of the virus's host range, evolutionary potential, and potential targets for neutralization.

Present and future: infectious tropical travel rashes and the impact of climate change

In this article, we discuss pertinent cutaneous findings with which patients may present after travel to tropical destinations. We address arthropod-borne infectious diseases such as cutaneous leishmaniasis, Chagas disease, cutaneous larva migrans, and myiasis. We discuss other relevant diseases with cutaneous signs such as monkey pox and severe acute respiratory syndrome coronavirus 2. We provide clinicians with information regarding the background, diagnosis, treatment, and prevention of these tropical rashes. In addition, we address the impact that climate change will have on the temporal and geographic incidence of these rashes. Viral, fungal, and vector-borne diseases have seen a geographic expansion into more northern latitudes. Among these are tick-borne Lyme disease, aquatic snail-related seabather's eruption, and atopic dermatitis. As these diseases spread, we believe that the updated information within this article is significant to the practicing physician in today's warming world.

Human Monkeypox-A Global Public Health Emergency

Monkeypox, a viral zoonosis caused by an Orthopoxvirus, is clinically characterized by fever, headache, lymphadenopathy, myalgia, rash and burdened by some complications that can be severe and life threatening. Monkeypox, endemic in some central and west African countries, in tropical areas near equator, rose to the headlines following its recent outbreak in non-endemic countries of Europe and the USA. Thus, the World Health Organization, worried about the growing dimension of the problem, declared monkeypox a global public health emergency. Now, after months of careful observation, the western scientific research is drawing conclusion that African endemic countries represent a reserve pool able to feed, through travelers and sexual networks, the outbreak in non-endemic countries in which high-risk communities such as gay and bisexual men are the most affected. Prevention through vaccination and early diagnosis are the core to breaking the chain of diffusion of this epidemic. Particular attention should be paid to avoid the spread from endemic countries, also implementing the economic investments in their public health system. Information campaigns and assistance to high-risk classes in non-endemic countries are important priorities, however, assuming that specific treatments for this disease are still tentative.

The basic reproductive ratio of the 2022 outbreak of the monkey pox virus disease for the United Kingdom, Canada, Brazil, the United Arab Emirates, and Nigeria

Background

A recent outbreak of the monkey pox virus disease (MPVD) started to spread over the world before the second half of the 2022 year. This outbreak of the monkey pox virus disease is known as the 2022 outbreak of the monkey pox virus disease. The monkey pox virus disease is a type of the pox disease similar to the human one. This disease is an endemic in some African countries; however, a new spreading of this disease started to appear in other countries, such as the Spain, brazil, Greece, the United Kingdom, and Portugal, Australia, and the USA. As of the end of September 2022, the MPVD spread over than 107 countries over the world.

Results

This study focuses on the employing of the simplest model of the diseases forecasting which is SIRD model for the finding of the basic reproductive ratio of the monkey pox virus disease in multiple countries over the world where the disease spreads. The model takes into accounts the number of the susceptible people, the number of the infectious people, the number of the recovered people, and the number of the deceased people. Based on the results of the SIRD model coefficients, we find that the basic reproductive ratio values of the recent spreading of the monkey pox virus disease are 1.3274 for the United Kingdom where the first case of the disease was recorded, 1.0714 for the United Arab Emirates, 1.0866 for Nigeria, 1.5589 for Brazil, and 1.3610 for Canada.

Conclusions

We find that the average value of the basic reproductive ratio of the 2022 outbreak of the monkey pox virus disease is about 1.2809. This important result of our calculations predicts that the 2022 outbreak of the monkey pox virus disease is turned into pandemic over the world. The things which confirm this result, based on our calculations, are the values of the basic reproductive ratio of the 2022 outbreak of the disease in the considered countries from multiple continents where all the values of the basic reproductive ratio are bigger than one. From this point, the counties over the world must apply multiple procedures for limiting the spreading of the monkey pox virus disease.

Graphical Abstract