Monkeypox infection: An update for the practicing physician

Oropouche virus infection: What internal medicine physicians should know

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Emerging Challenges of Mpox Transmission: An In-depth Scoping Review and Evidence Mapping on Breastfeeding Practices in South America

BACKGROUND

In 2022, a marked escalation in Monkeypox (Mpox) cases was observed in nonendemic regions, notably South America, despite the virus being traditionally endemic to Central and West Africa. This unexpected shift necessitated a deeper exploration of the novel transmission dynamics, including breastfeeding, given the emerging evidence of potential horizontal and vertical Mpox transmission during mother-infant interactions.

RESEARCH AIM

The study aimed to critically evaluate existing evidence on potential horizontal and vertical Mpox transmission related to breastfeeding and to assess guidelines in South American countries regarding Mpox prevention during breastfeeding.

METHODS

A scoping review and evidence mapping were conducted, adhering to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guideline. Data extraction involved identifying primary studies evaluating breastfeeding as a transmission route. Additionally, official documents from South American Health Ministries detailing guidelines or policies on breastfeeding in the context of maternal Mpox infection were reviewed.

RESULTS

Three out of 215 studies were found relevant; 2 were case reports, and 1 was a laboratory study. Available evidence suggests that contamination could likely occur horizontally through skin-to-skin contact. Six South American countries had issued guidelines on breastfeeding during Mpox infection, but the guidance varied and was not consistent across the region.

CONCLUSIONS

The study emphasizes the need for clear and consistent guidelines on breastfeeding during Mpox outbreaks, particularly in South America. Collaborative strategies and regular research updates will be essential in addressing the ongoing public health challenge.

Severe Presentation of Mpox With Skin, Lung and Pleural Involvement in a Non-HIV-Infected Kidney Transplant Recipient

Monkeypox (mpox) is an orthopoxviral zoonotic disease with a similar but less severe clinical presentation as smallpox. However, immunocompromised patients such as solid organ transplant recipients are at higher risk of developing severe forms of the disease. Herein, we describe the case of a 43-year-old female kidney transplant recipient that manifested severe skin ulcers alongside nodular lung opacities and pleural effusion attributed directly to the monkeypox virus. Notwithstanding the initiation of early treatment with tecovirimat, a satisfactory response was not achieved until a reduction in immunosuppression to everolimus monotherapy, coupled with the transition to cidofovir for antiviral treatment. In conclusion, mpox has the potential to produce a severe form of systemic infection in individuals who have undergone solid organ transplantation, demanding a meticulous approach involving sequential antiviral treatment and modifications to immunosuppressive regimens in order to achieve complete healing.

A Review of Mpox Outbreak and Public Health Response in Spain

Objective

In May 2022, an unprecedented Mpox outbreak was reported in several non-endemic countries with unknown epidemiological links. Since May 2022, more than 20,000 cases have been reported in Europe. Spain has been the most affected country in Europe. We aim to describe the Mpox epidemiological profile in Spain, identify its outbreak risks, and describe public health interventions implemented by the Spanish authorities.

Methods

A literature review was conducted, using specific selection criteria to obtain relevant publications describing Mpox clinical presentation and risk factors and the public health response in Spain to the ongoing outbreak.

Results

63.1% of the cases presented an anogenital rash, considered a specific and early symptom in this outbreak. Low case fatality rate is observed, mainly in risk groups, such as the immunocompromised population. Patients evolution was generally favorable, although 3-8% required hospitalization and two deaths occurred; 40% of patients were previously diagnosed with HIV infection. Most of the cases were seen among young population and concentrated in men who had sex with other men, mainly with multiple sexual partners, who did not practice safe sex such as using condoms, and those attending mass event parties.

Conclusion

To date, the Mpox outbreak is not considered a public health emergency of international concern. The epidemiological trend of the virus in Spain shows that public health response interventions (health education, contact tracing, vaccination, etc.) have adequately controlled the epidemic curve in high-risk populations and avoided spreading the virus to other groups within the community.

Mpox in Northeast Brazil: Spatiotemporal analysis and predictors associated with confirmed diagnosis

The mpox outbreaks reported in several countries from May 2022 have shown an epidemiological profile different from that observed in previous years, raising a global public health alert. This issue is particularly important for Brazil, the second country with the highest number of mpox cases. Herein, we performed a retrospective cross-sectional study on mpox cases notified in Pernambuco state, northeastern Brazil, between July 2022 and March 2023. Confirmed mpox cases were analyzed in a space-time series and their social and clinical characteristics were compared with those of suspect-negative cases, including a multivariate logistic regression to identify predictors associated with a positive diagnosis. A total of 1493 suspected mpox cases were reported, of which 362 cases (24.2%) were confirmed and distributed in 33 municipalities. Most mpox cases occurred between epidemiological weeks (EW) 33 and 39 of 2022, with the highest moving average in EW 34 and 35 (36 and 31.5, respectively). The most frequent clinical signs and symptoms were rash (87.3%), fever (60.2%), headache (45.3%), and genital/perianal lesions (40.3%). In the multivariate analysis, three variables showed considerable performance in predicting a positive mpox diagnosis (area under the ROC curve = 0.87; 95% CI: 0.84-0.90): sexual orientation (nonheterosexual; OR: 23.08; 95% CI: 13.97-38.15), male sex (OR: 2.05; 95% CI: 1.10-3.85), and multiple partnerships (OR: 1.95; 95% CI: 1.15-3.32). Overall, in addition to the detailed spatiotemporal description of mpox cases, which may contribute to appropriate public health measures, our study brings insights into mpox epidemiology by describing predictors associated with a positive diagnosis.

Neurological manifestations of an emerging zoonosis-Human monkeypox virus: A systematic review

BACKGROUND

The last few decades have witnessed an appalling rise in several emerging and re-emerging viral and zoonotic outbreaks. Amongst those emerging zoonosis, one of the diseases which is gaining popularity these days and has been declared as public health emergency of international concern by the world health organization, is human monkeypox virus (HMPX). Proper understanding of the clinical spectrum of the disease is of paramount importance for early diagnosis and treatment. In this review, we aimed to study and quantify the neurological manifestations of HMPX virus infection.

METHODS

Any study, released prior to April 13, 2023, that reported neurological manifestations in patients infected by HMPX virus were reviewed systematically on PubMed, Scopus, Google Scholar, and Cochrane Library using the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement.

RESULTS

Our systematic review included data from 22 eligible studies: 10 cohort studies, 3 cross sectional studies, one retrospective study, 5 case series, and 2 case reports. The most commonly reported neurological manifestations of HMPX were headache (48.84%), myalgia (27.50%), fatigue (17.73%), and photophobia (4.43%). Uncommonly, HMPX can also present with visual deficit (0.57%), seizure (0.34%), encephalitis (0.8%), dizziness (0.34%), encephalomyelitis (0.23%), coma (0.11%), and transverse myelitis (0.11%).

DISCUSSIONS

Monkeypox virus usually presents with self-limiting painful rash, lymphadenitis, and fever, complications like secondary skin infection, eye problems and pneumonia can be life threatening, carrying a case fatality rate of 1% to 10%. Neurological manifestations are not uncommon and can further add-on to morbidity and mortality.

The Global Monkeypox (Mpox) Outbreak: A Comprehensive Review

Monkeypox (Mpox) is a contagious illness that is caused by the monkeypox virus, which is part of the same family of viruses as variola, vaccinia, and cowpox. It was first detected in the Democratic Republic of the Congo in 1970 and has since caused sporadic cases and outbreaks in a few countries in West and Central Africa. In July 2022, the World Health Organization (WHO) declared a public-health emergency of international concern due to the unprecedented global spread of the disease. Despite breakthroughs in medical treatments, vaccines, and diagnostics, diseases like monkeypox still cause death and suffering around the world and have a heavy economic impact. The 85,189 reported cases of Mpox as of 29 January 2023 have raised alarm bells. Vaccines for the vaccinia virus can protect against monkeypox, but these immunizations were stopped after smallpox was eradicated. There are, however, treatments available once the illness has taken hold. During the 2022 outbreak, most cases occurred among men who had sex with men, and there was a range of 7-10 days between exposure and the onset of symptoms. Three vaccines are currently used against the Monkeypox virus. Two of these vaccines were initially developed for smallpox, and the third is specifically designed for biological-terrorism protection. The first vaccine is an attenuated, nonreplicating smallpox vaccine that can also be used for immunocompromised individuals, marketed under different names in different regions. The second vaccine, ACAM2000, is a recombinant second-generation vaccine initially developed for smallpox. It is recommended for use in preventing monkeypox infection but is not recommended for individuals with certain health conditions or during pregnancy. The third vaccine, LC16m8, is a licensed attenuated smallpox vaccine designed to lack the B5R envelope-protein gene to reduce neurotoxicity. It generates neutralizing antibodies to multiple poxviruses and broad T-cell responses. The immune response takes 14 days after the second dose of the first two vaccines and 4 weeks after the ACAM2000 dose for maximal immunity development. The efficacy of these vaccines in the current outbreak of monkeypox is uncertain. Adverse events have been reported, and a next generation of safer and specific vaccines is needed. Although some experts claim that developing vaccines with a large spectrum of specificity can be advantageous, epitope-focused immunogens are often more effective in enhancing neutralization.

Interdisciplinary management of mpox-related local complications: report on a series of cases

Monkeypox (mpox) is a viral zoonosis, and human-to-human transmission can result from close contact with the respiratory secretions and mucocutaneous lesions of an infected person. The prodromal phase is followed by an eruptive phase, with skin and/or mucosal lesions that progress through several stages at different sites. In this study, we describe the importance of interdisciplinary care management and follow-up of patients with complicated mpox. A cross-sectional study was conducted from May 2022 until August 2022 at a secondary hospital in Madrid (Spain). Out of 100 patients with mpox seen at this institution, we selected and analyzed 11 with local complications. All the patients were male at birth, and the mean age was 32 (30-42) years. The clinical manifestations included skin rash or mucosal lesions, fever, myalgia and lymphadenopathies. The most frequent local complications were pharyngitis associated with dysphagia, penile edema, infection of the mucocutaneous lesions, and ulceration of the genital lesions. A multidisciplinary team was created for the care of patients with complications secondary to mpox. The team comprised dermatologists and specialists in infectious diseases, preventive medicine, and emergency medicine. This approach improved the ability to diagnose and treat early with supportive, topical, and systemic treatment. In our center most of the cases were self-limiting, and none were life-threatening. An interdisciplinary response to a public health alert enhances the management of complex patients and should be implemented in successive outbreaks of mpox.

Monkeypox: a review of epidemiological modelling studies and how modelling has led to mechanistic insight

Human monkeypox (mpox) virus is a viral zoonosis that belongs to the Orthopoxvirus genus of the Poxviridae family, which presents with similar symptoms as those seen in human smallpox patients. Mpox is an increasing concern globally, with over 80,000 cases in non-endemic countries as of December 2022. In this review, we provide a brief history and ecology of mpox, its basic virology, and the key differences in mpox viral fitness traits before and after 2022. We summarize and critique current knowledge from epidemiological mathematical models, within-host models, and between-host transmission models using the One Health approach, where we distinguish between models that focus on immunity from vaccination, geography, climatic variables, as well as animal models. We report various epidemiological parameters, such as the reproduction number, R0, in a condensed format to facilitate comparison between studies. We focus on how mathematical modelling studies have led to novel mechanistic insight into mpox transmission and pathogenesis. As mpox is predicted to lead to further infection peaks in many historically non-endemic countries, mathematical modelling studies of mpox can provide rapid actionable insights into viral dynamics to guide public health measures and mitigation strategies.

Recent Developments in Mpox Prevention and Treatment Options

Human mpox is an emerging epidemic in the world. The monkey pox virus (MPXV) belongs to the same family of zoonotic Orthopoxviridae as that of the smallpox virus and exhibits similar clinical symptomology. Information regarding its diagnostics, disease epidemiology, surveillance, preventive methods, and treatment strategies are being collated with time. The purpose of this review is to trace the recent events in the scientific platform that have defined new preventive and treatment strategies against mpox. A methodological approach has been used to gather data from the latest literature to comprehensively overview the emerging treatment options. The results portion will cover details regarding the prevention of mpox. It will also shed light on a brief description of contemporary vaccines and antiviral agents that have been evaluated for their treatment potential since the emergence of the mpox threat. These treatment options are setting the pace for controlling the widespread monkeypox infection. However, the limitations attached to these treatment strategies need to be tackled quickly to increase their efficacy so that they can be deployed on a large scale for the prevention of this epidemic becoming another pandemic in this decade.

Clinical Manifestation, Transmission, Pathogenesis, and Diagnosis of Monkeypox Virus: A Comprehensive Review

Monkeypox virus is a double-stranded DNA virus species that causes disease in humans and mammals. It is a zoonotic virus belongs the genus Orthopoxviral, the family of Poxviridae, associated with the smallpox virus in many aspects. The first human case of monkeypox was reported throughout the Democratic Republic of Congo in 1970. In April 2022, several cases were recorded in widespread regions of Africa, the Northern and western hemispheres. The current review spotlights taxonomic classification, clinical presentations during infection, and the pathogenicity of the monkeypox virus in humans. Furthermore, the current review also highlights different diagnostics used for virus detection.

Mpox in Children and Adolescents: Epidemiology, Clinical Features, Diagnosis, and Management

Although mpox is rare among children in the United States, pediatric cases are being reported during the 2022 multinational mpox outbreak. Vaccines and antiviral medications developed for other orthopoxviruses have recently become widely used to prevent and treat mpox in both children and adults in the United States. Although scientific literature regarding mpox in children and adolescents is scant, prior case reports can provide valuable information about the clinical features and potential complications of untreated clade II mpox in these age groups. In this review, we summarize the epidemiology and clinical features of mpox in children and adolescents and provide recommendations for clinicians regarding its diagnosis, management, and prevention. Robust, dedicated surveillance of pediatric exposures and cases in the current outbreak, including the use of vaccines and therapeutics, are needed to guide clinical management and public health strategies.

The land-scape of immune response to monkeypox virus

Human monkeypox is a viral zoonotic smallpox-like disease caused by the monkeypox virus (MPXV) and has become the greatest public health threat in the genus Orthopoxvirus after smallpox was eradicated. The host immune response to MPXV plays an essential role in disease pathogenesis and clinical manifestations. MPXV infection leads to skin lesions with the genital area as the main feature in the current outbreak and triggers a strong immune response that results in sepsis, deep tissue abscess, severe respiratory disease, and injuries to multiple immune organs. Emerging evidence shows that the immunopathogenesis of MPXV infection is closely associated with impaired NK-cell function, lymphopenia, immune evasion, increased antibodies, increased blood monocytes and granulocytes, cytokine storm, inhibition of the host complement system, and antibody-dependent enhancement. In this overview, we discuss the immunopathology and immunopathogenesis of monkeypox to aid the development of novel immunotherapeutic strategies against monkeypox.

A review on monkeypox virus outbreak: New challenge for world

Background

Monkeypox is a viral zoonotic disease caused by the monkeypox virus, a double-stranded DNA-enveloped virus that can be transmitted from animal to human or human to human. Consequently, it emerged as the most important orthopoxvirus for public health. Based on available online literature, this study reviewed the majority of the data representing the outbreak, diagnosis, treatment, and prevention of monkeypox.

Methods

The literature search was conducted between July 5 and September 15, 2022. In addition to reviewing the databases of World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Africa CDC, and United Kingdom Health Security Agency monkey pox advice, 43 papers were studied in depth.

Results and Discussion

Human monkeypox was first identified in 1970 in a child in the Democratic Republic of the Congo. Until May 6, 2022, it was endemic in West and Central African countries and infrequently occurred outside of Africa. However, many cases have been identified in several nonendemic countries since May 13, 2022, with no prior human or animal travel from endemic areas; that was the first time to document the cases and long-term transmission in countries with no epidemiological ties to endemic African countries. Seven travel-related human monkeypox cases were recorded outside of Africa from September 2018 to November 2021: one in Israel, one in Singapore, and two in the US Youth are most affected. Monkeypox's unanticipated development in places with no known epidemiological linkages raises concerns about the virus's evolution, which permits undetected transmission for a long period.

Conclusion

Monkeypox is no longer a rare, self-limiting disease limited to endemic countries. Its ever-changing epidemiology and transmission dynamics have increased the possibility of its evolving into a much deadlier pathogen. Therefore, improved surveillance and detailed case and contact investigation are required to comprehend the ever-changing epidemiology of monkeypox.

Epidemiological Situation of Monkeypox Transmission by Possible Sexual Contact: A Systematic Review

Monkeypox (MPX), a zoonotic infection caused by the monkeypox virus (MPXV), has re-emerged worldwide with numerous confirmed cases with person-to-person transmission through close contacts, including in sexual networks. Therefore, this study aimed to determine the epidemiological situation of monkeypox transmission by possible sexual contact. A systematic literature review was conducted using PubMed, Scopus, Web of Science, and Embase databases until 18 August 2022. The key search terms used were "monkeypox", "sexual contact", "sexual intercourse" and "sexual transmission". A total of 1291 articles were retrieved using the search strategy. After eliminating duplicates (n = 738) and examining by title, abstract, and full text, 28 studies reporting case reports of monkeypox with a detailed description of clinical features, sexually transmitted diseases, method of diagnosis, location and course of skin lesions, and treatment were included. A total of 4222 confirmed cases of monkeypox have been reported, of which 3876 monkeypox cases are the result of transmission by sexual contact distributed in twelve countries: 4152 cases were male with a mean age of 36 years. All confirmed cases of monkeypox were diagnosed by reverse transcriptase-polymerase chain reaction (RT-PCR). The most frequent clinical manifestations were fever, lymphadenopathy, headache, malaise, and painful perianal and genital lesions. The most frequent locations of the lesions were perianal, genital, oral, trunk, upper and lower extremities. Patients were in good clinical condition, with treatment based on analgesics and antipyretics to relieve some symptoms of monkeypox. A high proportion of STIs and frequent anogenital symptoms were found, suggesting transmissibility through local inoculation during close skin-to-skin or mucosal contact during sexual activity. The highest risk of monkeypox transmission occurs in men who have sex with men, and MPXV DNA could be recovered in seminal fluid. It is essential to establish health policies for the early detection and management of patients with monkeypox.