Monkeypox outbreak in Madrid (Spain): Clinical and virological aspects

Mpox cases finding: Evaluation of a Primary Care detection program in the Northern Metropolitan area from Barcelona (Spain)

MAIN AIM

In July 2022, an extensive outbreak of Mpox (monkeypox) was considered by WHO as a Public Health Emergency. The objective of this study is to describe the obtained results from a Mpox case detection program in a semi-urban healthcare area where approximately 420 Primary Care physicians work.

DESIGN

An observational prospective study performed between June 01, 2022 and December 31, 2023.

SETTING

The Northern Metropolitan area of Barcelona, with 1400.000hab (Catalonia, Spain).

METHODS

An unified Mpox management procedure was agreed, including a prior online training of Primary Care professionals, to individually assess all Mpox suspected cases from a clinical and epidemiological perspective.

PARTICIPANTS

All patients who met clinical and/or epidemiological criteria of Mpox.

DATA COLLECTION

Age, gender, risk classification (suspected/probable), cluster-linked (yes/no), high-risk sexual contact (yes/no), general symptoms, genital lesion and final diagnostic.

RESULTS

A total of 68 suspected Mpox cases were included, from which 16 (26.6%) were Mpox confirmed by PCR. Up to 13 (81.2%) were male and, among them, 12 (75%) men who have sex with men (MSM). The series, however, included two minors and three women. Among MSM, 3 (18.7%) were HIV positive and 3 had no regular access to the Public Healthcare system. Among discarded patients, any infectious disease was diagnosed in 55% of cases.

CONCLUSIONS

In spite of the short series, this Primary Care community-based study identified a sub-population group showing a different profile of Mpox cases compared to other published series (lower HIV prevalence, higher representativeness of heterosexual transmission and hard to reach population).

Severe mpox requiring colostomy in a patient with advanced HIV disease: A case report and literature review

This severe monkeypox case described a 23-year-old male with advanced HIV-1 disease presenting perirectal abscess, extensive anal ulcerative lesions requiring colostomy, and tecovirimat resistance. Radiologically non-liquefied perirectal abscess presented diagnostic challenges highlighting the complexity of aggressive monkeypox manifestations in immunocompromised individuals.

Sexually transmitted diseases and HIV co-infection among adult male patients in the 2022 monkeypox outbreak: a systematic review and meta-analysis

This meta-analysis estimates sexually transmitted disease (STI) and HIV rates in male monkeypox patients during the 2022 outbreak. The study examines contextual factors that increase monkeypox risk. A systematic review of PubMed/Medline, Scopus, and Google Scholar was conducted to find observational studies on monkeypox patients' demographics and medical characteristics from the 2022 outbreak. This review's meta-analysis followed the System for the Unified Management, Assessment, and Review of Information - Joanna Briggs Institute (SUMARI JBI) guidelines. All HIV and STI prevalence data for male monkeypox patients was exported into the SUMARI JBI. For point prevalence of HIV and STIs, we used the Freeman-Tukey-type arcsine square root transformation to stabilize raw proportion variances. A fixed-effects model weighted and pooled all estimates by inverse variance. We then used a random model to account for sampling variation and reported fixed-effect model effect size heterogeneity across studies. Study heterogeneity was measured using the I2 test statistic and P-values. I2 test results were interpreted as low (25%), moderate (50%), and high (75%). Six Spanish and English studies qualified. These studies included 541 male monkeypox patients, 214 of whom had HIV and 255 with other STIs. HIV prevalence was estimated at 40% (95% CI = 0.31%, 0.50%; ᵡ2=15) and STIs at 43% (95% CI = 25%, 61%; ᵡ2=118). Overall, analyses showed moderate to high heterogeneity. Four in ten male monkeypox patients in 2022 had HIV or other STIs. To prevent HIV and other STIs, public health measures should target male and female monkeypox patients.

MPXV DNA kinetics in bloodstream and other body fluids samples

Since spring 2022, the global epidemiology of the monkeypox virus (MPXV) has changed. The unprecedented increase of human clade II MPXV cases worldwide heightened concerns about this emerging zoonotic disease. We analysed the positivity rates, viral loads, infectiousness, and persistence of MPXV DNA for up to 4 months in several biological samples from 89 MPXV-confirmed cases. Our data showed that viral loads and positivity rates were higher during the first two weeks of symptoms for all sample types. Amongst no-skin-samples, respiratory specimens showed higher MPXV DNA levels and median time until viral clearance, suggesting their usefulness in supporting MPXV diagnosis, investigating asymptomatic patients, and monitoring viral shedding. Infectious virus was cultured from respiratory samples, semen, and stools, with high viral loads and collected within the first 10 days. Notably, only one saliva and one semen were found positive for viral DNA after 71 and 31 days from symptoms, respectively. The focus on bloodstream samples showed the best testing sensitivity in plasma, reporting the overall highest MPXV DNA detection rate and viral loads during the 3-week follow-up as compared to serum and whole-blood. The data here presented can be useful for MPXV diagnostics and a better understanding of the potential alternative routes of its onward transmission.

A global systematic evidence review with meta-analysis of the epidemiological characteristics of the 2022 Mpox outbreaks

BACKGROUND

In 2022, there were outbreaks of Mpox where the disease is not endemic. We summarized published full-text epidemiological data from the outbreaks.

METHODS

A global evidence review (protocol: osf.io/j3kb7) with systematic literature search up to February 09, 2023. We focused on experimental/observational studies of laboratory confirmed Mpox, excluding case reports and case series of < 5 cases. Epidemiological data were pooled using an inverse variance, random-effects model, and pooled estimates presented with associated 95% confidence intervals.

RESULTS

We included 66 studies. Mean incubation period was 7.8 days (6.6-9.0 days, 8 studies: 560 cases), reproductive number 1.8 (1.7-1.9, 6 studies), mean duration from symptom onset to diagnosis 5.8 days (4.8-6.8 days, 4 studies: 982 cases), mean symptom duration 17.5 days (14.7-20.2 days, 3 studies: 292 cases), mean serial interval 8.5 days (7.3-9.9 days, 1 study), hospitalisation 6% (4-9%, 26 studies: 5339 cases), and vaccine effectiveness 78% (65-91%, 3 studies: 953 cases). Highly relevant clinical manifestations were pleomorphic skin lesions 82% (68-94%, 26 studies: 4093 cases), anogenital lesions 64% (51-77%, 9 studies: 10,398 cases), fever 54% (50-57%, 52 studies: 25,992 cases), and lymphadenopathy 51% (46-57%, 42 studies: 17,803 cases), with cases mostly men who have sex with men (MSM). Possibly relevant manifestations were perianal lesions, fatigue, asthenia, myalgia, and headache.

CONCLUSIONS

The 2022 Mpox outbreaks presented with sex-related clinical manifestations and were mostly reported among MSM.

Cytokine storm in human monkeypox: A possible involvement of purinergic signaling

Some evidence has indicated that monkeypox can induce a cytokine storm. Purinergic signaling is a cell pathway related to the cytokine storm. However, the precise mechanisms that lead to cytokine storms in monkeypox infections and the possible involvement of purinergic signaling in the immune response to this virus remain unknown. In this review article, we aimed to highlight a body of scientific evidence that consolidates the role of the cytokine storm in monkeypox infection and proposes a new hypothesis regarding the roles of purinergic signaling in this immune-mediated mechanism. We further suggested some purinergic signaling modulators to mitigate the deleterious and aggravating effects of immune dysregulation in human monkeypox virus infection by inhibiting P2X3, P2X7, P2Y2, and P2Y12, reducing inflammation, and activating A1 and A2A receptors to promote an anti-inflammatory response.

Mpox across countries from Central and Eastern Europe - 2022 outbreak

BACKGROUND

The aim of the study was to assess socio-demographical characteristics, clinical presentation, and outcomes in patients diagnosed with mpox.

METHODS

A survey on patients diagnosed with mpox was performed in 14 countries from Central and Eastern Europe. Data was compared according to HIV status and country of origin (EU vs. non-EU). Mpox diagnosis was confirmed by RT-PCR from oropharyngeal swabs, skin lesions, and other body fluids.

RESULTS

Out of 154 patients confirmed with mpox in 2022, 99.3% were males, with a median age (years) of 35 (IQR 30-39), 90.2% MSM and 48.7% PLWH. Compared to HIV-negative subjects, PLWH had more frequent high-risk behaviours:chemsex (p = 0.015), group sex (p = 0.027), and a history of sexually transmitted infections (STIs) (p = 0.004). Persons from EU were more often PLWH (p = 0.042), MSM (p < 0.0001), had multiple sexual partners (p = 0.025), practiced chemsex (p = 0.008) or group-sex (p = 0.005) and had more often history of STIs (p < 0.0001). The median CD4 cell count/mL at mpox diagnosis was 713 (IQR 486-996) and 73.5% had undetectable HIV VL. The commonest clinical features were fever (108 cases), lymphadenopathy (78), and vesiculo-pustular rash: penile (76), perianal (48), limbs (67). Fifty-one (31%) persons were hospitalized due to complications or epidemiological reasons. Three patients received tecovirimat or cidofovir. The outcome was favorable for all patients, including 4 with severe forms.

CONCLUSIONS

Mpox was diagnosed predominantly in young MSM, with high-risk behaviors and history of STIs. Effective contact tracing and vaccination are important strategic pillars to control mpox outbreaks.

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.

Pan-microscopic examination of monkeypox virus in trophoblasts cells reveals new insights into virions release through filopodia-like projections

Vertical transmission has been described following monkeypox virus (MPXV) infection in pregnant women. The presence of MPXV has been reported in the placenta from infected women, but whether pathogens colonize placenta remains unexplored. We identify trophoblasts as a target cell for MPXV replication. In a pan-microscopy approach, we decipher the specific infectious cycle of MPXV and inner cellular structures in trophoblasts. We identified the formation of a specialized region for viral morphogenesis and replication in placental cells. We also reported infection-induced cellular remodeling. We found that MPXV stimulates cytoskeleton reorganization with intercellular extensions for MPXV cell spreading specifically to trophoblastic cells. Altogether, the specific infectious cycle of MPXV in trophoblast cells and these protrusions that were structurally and morphologically similar to filopodia reveal new insights into the infection of MPXV.

Atypical Mpox in a Nigerian Tertiary Health Facility

BACKGROUND

We describe diverse clinical characteristics and course of confirmed mpox cases managed in a Nigerian tertiary health facility.

METHODS

Clinical and epidemiologic data were analyzed, highlighting the unusual presentations of polymerase chain reaction (PCR)-confirmed mpox cases observed during the 2022 outbreak.

RESULTS

Out of 17 suspected cases, 13 (76.4%) were PCR confirmed for mpox. The mean ± SD age for the participants was 28.62 ± 10.29 years (range, 2-55), of which 9 (64.3%) were male. Of the 13 PCR-confirmed cases, 5 (38.5%) had varicella zoster virus coinfection, 2 (15.4%) had HIV coinfection, and 1 (7.7%) had diabetes mellitus comorbidity. All patients experienced rash, with 6 (46.2%) having significant genital lesions and 1 (7.7%) having a severe perianal lesion. A lack of prodromal symptoms was reported in 3 (23.1%), and a prolonged prodrome (>1 week) occurred in 5 (38.5%). Skin lesions were polymorphic in 6 (46.2%), and solitary skin lesions occurred in 3 (23.1%), which persisted for >120 days in 7.7%.

CONCLUSIONS

Clinical recognition, diagnosis, and prevention remain a concern in resource-limited settings. Our findings highlight the need to further evaluate unusual skin lesions and to include mpox screening for genital skin lesions that are presumed to be sexually transmitted infections. Revision of clinical case definition and enhanced surveillance are key to early recognition and prevention of spread.

Concurrent Sexually Transmitted Infections with Mpox Infections: A Brief Review

Mpox is a viral zoonotic infection endemic to countries in Central and West Africa. The outbreak that began in May 2022 is novel for its global spread and transmission through sexual encounters. Research of this outbreak shows a high rate of concurrent sexually transmitted infections (STIs) in patients with mpox, highlighting the need to consider STIs in mpox management, and to raise awareness of historically high levels of STIs caused by inadequacies in sexual health care. It is critical to prioritize sexual health and address health disparities to control current transmission of infections and prevent future outbreaks.

Monkeypox virus: insights into pathogenesis and laboratory testing methods

The monkeypox virus (MPXV) is a zoonotic pathogen that transmits between monkeys and humans, exhibiting clinical similarities with the smallpox virus. Studies on the immunopathogenesis of MPXV revealed that an initial strong innate immune response is elicited on viral infection that subsequently helps in circumventing the host defense. Once the World Health Organization (WHO) declared it a global public health emergency in July 2022, it became essential to clearly demarcate the MPXV-induced symptoms from other viral infections. We have exhaustively searched the various databases involving Google Scholar, PubMed, and Medline to extract the information comprehensively compiled in this review. The primary focus of this review is to describe the diagnostic methods for MPXV such as polymerase chain reaction (PCR), and serological assays, along with developments in viral isolation, imaging techniques, and next-generation sequencing. These innovative technologies have the potential to greatly enhance the accuracy of diagnostic procedures. Significant discoveries involving MPXV immunopathogenesis have also been highlighted. Overall, this will be a knowledge repertoire that will be crucial for the development of efficient monitoring and control strategies in response to the MPXV infection helping clinicians and researchers in formulating healthcare strategies.

Analysing monkeypox epidemic drivers: Policy simulation and multi-index modelling across 39 nations

Background

This study aimed to analyse the drivers of the monkeypox (Mpox) epidemic and policy simulation to support health care policies against the Mpox epidemic.

Methods

We established a three-round selection mechanism for 164 factors using Lasso and negative binomial regression to investigate the correlation between significant drivers and the cumulative confirmed cases of Mpox. Policy simulation for each driver was evaluated, and the varying effects of implementation at different times were examined.

Results

HIV/AIDS prevalence and air transport passengers carried were significant determinants of the risk of the Mpox epidemic across various countries, with regression coefficients of 1.417 and 0.766, respectively. A decrease in HIV/AIDS prevalence by 10, 20, 30, and 40% corresponded to reductions in the number of Mpox cases by 6.28, 6.55, 6.87, and 7.26%, respectively. Similarly, 20, 40, 60, and 80% travel restrictions led to reductions in Mpox cases by 7.16, 15.63, 26.28%, and 41.46%, respectively. Controlling air transport passengers carried in the first month could postpone outbreak onset by 0.5-2.0 months.

Conclusions

Mpox prevention and control policies should primarily focus on travel restrictions during high disease-risk periods and flight suspensions from high-risk nations in combination with regular HIV/AIDS prevention and treatment strategies.

Longitudinal Analysis of Mpox Virus DNA Detectability From Multiple Specimen Types During Acute Illness: A Cohort Study

Background

Longitudinal data on the detectability of monkeypox virus (MPXV) genetic material in different specimen types are scarce.

Methods

We describe MPXV-specific polymerase chain reaction (PCR) results from adults with confirmed mpox infection from Toronto, Canada, including a cohort undergoing weekly collection of specimens from multiple anatomic sites until 1 week after skin lesions had fully healed. We quantified the time from symptom onset to resolution of detectable viral DNA (computed tomography [Ct] ≥ 35) by modeling exponential decay in Ct value as a function of illness day for each site, censoring at the time of tecovirimat initiation.

Results

Among 64 men who have sex with men, the median (interquartile range [IQR]) age was 39 (32.75-45.25) years, and 49% had HIV. Twenty received tecovirimat. Viral DNA was detectable (Ct < 35) at baseline in 74% of genital/buttock/perianal skin swabs, 56% of other skin swabs, 44% of rectal swabs, 37% of throat swabs, 27% of urine, 26% of nasopharyngeal swabs, and 8% of semen samples. The median time to resolution of detectable DNA (IQR) was longest for genital/buttock/perianal skin and other skin swabs at 30.0 (23.0-47.9) and 22.4 (16.6-29.4) days, respectively, and shortest for nasopharyngeal swabs and semen at 0 (0-12.1) and 0 (0-0) days, respectively. We did not observe an effect of tecovirimat on the rate of decay in viral DNA detectability in any specimen type (all P > .05).

Conclusions

MPXV DNA detectability varies by specimen type and persists for over 3-4 weeks in skin specimens. The rate of decay did not differ by tecovirimat use in this nonrandomized study.

Infection prevention and control measures to reduce the transmission of mpox: A systematic review

OBJECTIVES

To make inferences regarding the effectiveness of respiratory interventions and case isolation measures in reducing or preventing the transmission of mpox based on synthesis of available literature.

METHODS

The WHO Clinical Management and Infection Prevention and Control 2022 guideline and droplet precautions in healthcare facilities and home isolation infection prevention control measures for patients with mpox. We conducted a systematic review that included a broad search of five electronic databases. In a two-stage process, we initially sought only randomized controlled trials and observational comparative studies; when the search failed to yield eligible studies, the subsequent search included all study designs including clinical and environmental sampling studies.

RESULTS

No studies were identified that directly addressed airborne and droplet precautions and home isolation infection prevention control measures. To inform the review questions the review team synthesized route of transmission data in mpox. There were 2366/4309 (54.9%) cases in which investigators identified mpox infection occurring following transmission through direct physical sexual contact. There were no reported mpox cases in which investigators identified inhalation as a single route of transmission. There were 2/4309 cases in which investigators identified fomite as a single route of transmission. Clinical and environmental sampling studies isolated mpox virus in a minority of saliva, oropharangeal swabs, mpox skin lesions, and hospital room air.

CONCLUSIONS

Current findings provide compelling evidence that transmission of mpox occurs through direct physical contact. Because investigators have not reported any cases of transmission via inhalation alone, the impact of airborne and droplet infection prevention control measures in reducing transmission will be minimal. Avoiding physical contact with others, covering mpox lesions and wearing a medical mask is likely to reduce onward mpox transmission; there may be minimal reduction in transmission from additionally physically isolating patients with mild disease at home.

Cases of Monkeypox show highly-overlapping co-infection with HIV and syphilis

Purpose

Ongoing Monkeypox (MPX) outbreaks in countries outside Africa have unique characteristics. However, data on cohorts of confirmed cases in China is limited. The study provides important epidemiological, diagnostic, and clinical information about this disease in China.

Methods

We report a series of Chinese individuals with confirmed MPX infections identified at Beijing Youan Hospital (China) from June 10 to July 15, 2023. Samples were taken from the skin, anus, throat, and blood. An epidemiological questionnaire was used to collect demographic and clinical data. Further, we compared the MPX viral (MPXV) loads across different anatomical sites.

Results

66 samples were collected from 20 patients, all of whom were cisgender men. Median patient age was 29 years. Notably, 19 (95%) patients reported unprotected sexual encounters with men in the preceding month, and 13 (65%) were human immunodeficiency virus (HIV)-positive. Among those with HIV, 12 (92%) were receiving antiretroviral therapy, and 11 (85%) had well-controlled infections (HIV viral load <40/mL). The median CD4+ T cell count was 667 cells/mm3. In the HIV-negative group, three (43%) patients were taking preexposure prophylaxis. Fifteen patients (75%) had concurrent sexually transmitted infections (50% had syphilis and 65% had HIV) and eight (40%) had HIV and syphilis co-infection. MPXV loads were significantly higher in samples from the skin (cycle threshold value [Ct value]: 19·0) and anus (Ct value: 23.0) compared to samples from the throat (Ct value: 31.0) or blood (Ct value: 34.5). All patients had skin lesions (85% of whom presented with anogenital lesions). Common systemic symptoms included fever (85%) and lymphadenopathy (55%). The median incubation period was 8 d [interquartile range (IQR): 6-16 d]. The median time from the onset of skin lesions to scab removal was 14 d (IQR: 10-16 d). No deaths or severe cases were reported.

Conclusion

MPXV primarily affects young homosexual men. The high MPXV viral loads in skin and anal lesions indicate that transmission most likely occurs through direct and close body contact. This study also reports high rates of HIV and syphilis co-infection. Therefore, preventive efforts should focus on homosexual men.

The re-emergence and transmission of Monkeypox virus in Nigeria: the role of one health

The Monkeypox virus, commonly abbreviated as mpox, is a viral zoonosis that is experiencing a resurgence in prevalence. It is endemic to regions of West and Central Africa that are characterized by dense forested areas. Various measures pertaining to animals, humans, and the environment have been recognized as potential factors and catalysts for the spread of the disease throughout the impacted regions of Africa. This study examines the various factors contributing to the transmission of the virus in Nigeria, with a particular focus on the animal-human and inter-human modes of transmission in rural communities and healthcare facilities. The One Health approach was emphasized as crucial in the prevention and management of this issue. Literature suggests that preventing repeated zoonotic introductions could potentially halt the transmission of the mpox virus from animal to human hosts, leading to a potential decrease in human infections.

How news reporting exacerbated the monkeypox pandemic in Spain and the US: A corpus-based news values analysis

Media reporting greatly influences the civilians' mentality, which further exacerbates or mitigates outbreaks of infectious diseases, prolongs or shortens the pandemic process. Adopting corpus linguistic methods and Discursive news values analysis (DNVA) framework, this study examined the news values through key words, naming strategies and photographs in monkeypox-themed news reporting in Spanish and the US media, to analyse how they constructed the monkeypox pandemic in their news reporting, sold it to the public and exacerbated the pandemic in the two societies. The results show that the Spanish media constructed the monkeypox pandemic predominantly as an international medical event, distancing the monkeypox pandemic from the Spanish indigenous context and depriving the domestic audiences from the sense of urgency to take prevention actions. On the other hand, the US media mainly packaged the monkeypox pandemic as a political event which isolated this public health crisis from the life of the common people and hindered the US citizens' understanding of the requisite medical information about the monkeypox virus. It is concluded that the lack of indigenous focus of the Spanish media, and the excessively politicised focus of the US media are important factors that lead to the exacerbation of the monkeypox epidemic.

Poxviridae Pneumonia

Poxviridae family includes several viruses that infecting humans usually causes skin lesions only, but in some cases their clinical course is complicated by viral pneumonia (with or without bacterial superinfections). Historically variola virus has been the poxviridae most frequently associated with the development of pneumonia with many large outbreaks worldwide before its eradication in 1980. It is still considered a biological threat for its potential in biological warfare and bioterrorism. Smallpox pneumonia can be severe with the onset of acute respiratory distress syndrome (ARDS) and death. Vaccinia virus, used for vaccination against smallpox exceptionally, in immunocompromised patients, can induce generalized (with also lung involvement) severe disease after vaccination. MPXV virus occasionally can cause pneumonia particularly in immunocompromised patients. The pathophysiology of poxviridae pneumonia is still an area of active research; however, in animal models these viruses can cause both direct damage to the lower airways epithelium and a hyperinflammatory syndrome, like a cytokine storm. Multiple mechanisms of immune evasion have also been described. The treatment of poxviridae pneumonia is mainly based on careful supportive care. Despite the absence of randomized clinical trials in patients with poxviridae pneumonia there are antiviral drugs, such as tecovirimat, cidofovir and brincidofovir, FDA-approved for use in smallpox and also available under an expanded access protocol for treatment of MPXV. There are 2 (replication-deficient modified vaccinia Ankara and replication-competent vaccinia virus) smallpox vaccines FDA-approved with the first one also approved for prevention of MPXV in adults that are at high risk of infection.

Clinical characteristics and outcomes of patients with mpox during the 2022 mpox outbreak compared with those before the outbreak: A systematic review and meta-analysis

On 23 July 2022, the World Health Organization declared the global mpox outbreak as a public health emergency of international significance. The mpox virus (MPXV) that caused the outbreak was classified as clade IIb, which belongs to the West African clade. However, the relationship between MPXV clades and symptoms, as well as the severity of mpox outcomes, is not fully understood. Thus, we aimed to investigate the global mpox prevalence and the differences in clinical manifestations and outcomes among patients with mpox between pre-outbreak (2003-2021) and the current mpox outbreak. In this systematic review and meta-analysis, PubMed/MEDLINE, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature, and Google Scholar were searched using the keyword "monkeypox" and "mpox" up to 13 October 2022. A random effects model was used to obtain the pooled prevalence and 95% confidence intervals. This study included 27 articles, and 5698 patients with mpox with 19 distinctive features from 19 countries across five continents were assessed. Patients with mpox during the 2022 mpox outbreak showed mild clinical manifestations and outcomes compared with those before the 2022 mpox outbreak: mild rash (relative ratio [RR]: 5.09, 95% confidence interval [CI]: 1.52-17.08), fever (0.68, 0.49-0.94), pruritus (0.25, 0.19-0.32), myalgia (0.50, 0.31-0.81), headache (0.56, 0.35-0.88), skin ulcer (0.32, 0.17-0.59), abdominal symptom (0.29, 0.20-0.42), pharyngitis (0.32, 0.18-0.58), nausea or vomiting (0.15, 0.02-0.93), conjunctivitis (0.11, 0.03-0.38), concomitant infection with HIV (1.70, 0.95-3 0.04), and death (0.02, 0.001-0.31). MPXV clade IIb exhibited higher infectivity but may cause mild disease symptoms and low mortality rate. It is important to consider MPXV infection in patients with mpox-related features and/or a history of sexual transmission to prevent the spread of the disease and recognise the current pandemic threat.

HIV and mpox: a rapid review

In this review, we discuss the history and epidemiology of mpox, prevention strategies, clinical characteristics and management, severity of mpox among persons with advanced HIV, and areas for future research relevant to persons with HIV.

Mpox in a Couple Living with HIV: Relapse or Reinfection?

Mpox is caused by a zoonotic orthopoxvirus capable of infecting several animal species, including humans. The analysis of cases in the current outbreak showed that, differently from what happens in the classical disease, mpox has mostly affected men who have sex with men (MSM) and bisexuals, including a high proportion of people living with HIV/AIDS. The role of the immune system in fighting mpox has been discussed in literature and experts believe that immunity conferred by natural infection may be lifelong, advocating against the possibility of reinfection by monkeypox virus. This report presents a MSM couple living with HIV with cycles of mpox lesions after two different risk exposures. The clinical course of both cases, as well as the temporal and anatomical relationship between the second cycle of monkeypox virus lesions and the second exposure, suggests the occurrence of reinfection. The genomic surveillance of monkeypox virus, a better understanding of its interaction with the human host, and knowledge of the postinfection and postvaccine protection correlation are more relevant at this moment, when we observe an intersection of the mpox multicountry outbreak with the HIV/AIDS epidemic, considering the immunosenescence and other immune system issues caused by HIV.

Epidemiology of mpox: Focus on men with HIV

The 2022 mpox outbreak is the first ever report of worldwide spread of cases. Integrated knowledge on the epidemiology and clinical characteristics of mpox are limited. This study was conducted to shed light on the epidemiology of 2022 mpox outbreak. We found that men were the most infected sex (90-100 % cases). The highest prevalence of mpox infection (70 %) was found among men aged between 30 and 40 years. Pre-existing HIV was reported among 24-100 % of mpox positive cases. About 90-100 % of the cases have been disproportionately found among group of men with specific sexual practice, namely, men who have sex with men (MSM). Case fatality rate of 2022 mpox outbreak varied between 1 and 10 %. Studies on the relationship of HIV with mpox outcomes are limited. This study will add knowledge on the epidemiology of 2022 mpox outbreak.

Mpox global outbreak: update in epidemiology, clinical spectrum and considerations in prevention and treatment

Mpox is the most prevalent Orthopoxvirus infection in humans. Several clinical characteristics of mpox distinguish this disease from other rash illnesses. Complications are not uncommon. New therapeutics and vaccines are likely to change the course of the disease, especially in immunocompromised individuals. Clinicians must ensure that access to treatment and prevention measures are guaranteed especially in this particular population. This review exposes the epidemiology, clinical spectrum and updated considerations in treatment and prevention within the mpox global outbreak.

Sexually transmitted infections in Spain: Current status

Sexually Transmitted Infections (STI) are a major public health problem. The problems inherent to their diagnosis, treatment and prevention have to do not only with their nature, but also with organizational issues and overlapping competencies of the different health authorities in Spain. The real situation of STI in Spain, at present, is poorly known. For this reason, the Scientific Committee on COVID and Emerging Pathogens of the Illustrious Official College of Physicians of Madrid (ICOMEM) has formulated a series of questions on this subject which were distributed, not only among the members of the Committee, but also among experts outside it. The central health authorities provide very high and increasing figures for gonococcal infection, syphilis, Chlamydia trachomatis infection and lymphogranuloma venereum (LGV). Both HIV infection and Monkeypox are two important STI caused by viruses in our environment, to which it should be added, mainly, Herpes simplex virus (HSV) and Human papillomavirus (HPV) infections. Emerging microorganisms such as Mycoplasma genitalium pose not only pathogenic challenges but also therapeutic problems, as in the case of N. gonohrroeae. The pathways that patients with suspected STI follow until they are adequately diagnosed and treated are not well known in Spain. Experts understand that this problem is fundamentally managed in public health institutions, and that Primary Care and Hospital Emergency Services, together with some institutions that deal monographically with this problem, are the recipients of most of these patients. One of the most serious difficulties of STI lies in the availability of the microbiological tests necessary for their diagnosis, particularly in this era of outsourcing of microbiology services. Added to this is the increased cost of implementing the latest generation of molecular techniques and the difficulties of transporting samples. It is clear that STI are not diseases to which the entire population is equally exposed and it is necessary to have a better knowledge of the risk groups where to focus the necessary interventions adapted to their characteristics. It should not be forgotten that STI are also a problem in the pediatric age group and that their presence can be a marker of sexual abuse with all that this implies in terms of health care and medicolegal activity. Finally, STI are infections that are associated with a high cost of care for which we have very little information. The possibility of expanding the automatic performance of laboratory tests for STI surveillance through laboratory routines is encountering ethical and legal problems that are not always easy to solve. Spain has created a ministerial area of specific attention to STI and there are plans to improve the diagnosis, treatment and prevention of these problems, but we still lack the necessary evidence on their impact. We cannot forget that these are diseases that transcend the individual and constitute a Public Health problem.

Molecular epidemiology, transmission and clinical features of 2022-mpox outbreak: A systematic review

Background and Aims

The 2022-mpox outbreak has spread worldwide in a short time. Integrated knowledge of the epidemiology, clinical characteristics, and transmission of mpox are limited. This systematic review of peer-reviewed articles and gray literature was conducted to shed light on the epidemiology, clinical features, and transmission of 2022-mpox outbreak.

Methods

We identified 45 peer-reviewed manuscripts for data analysis. The standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and Cochrane Collaboration were followed for conducting the study.

Results

The case number of mpox has increased about 100 times worldwide. About 99% of the cases in 2022 outbreak was from non-endemic regions. Men (70%-98% cases) were mostly infected with homosexual and bisexual behavior (30%-60%). The ages of the infected people ranged between 30 and 40 years. The presence of HIV and sexually transmitted infections among 30%-60% of cases were reported. Human-to-human transmission via direct contact and different body fluids were involved in the majority of the cases (90%-100%). Lesions in genitals, perianal, and anogenital areas were more prevalent. Unusually, pharyngitis (15%-40%) and proctitis (20%-40%) were more common during 2022 outbreak than pre-2022 outbreaks. Brincidofovir is approved for the treatment of smallpox by FDA (USA). Two vaccines, including JYNNEOSTM and ACAM2000®, are approved and used for pre- and post-prophylaxis in cases. About 100% of the cases in non-endemic regions were associated with isolates of IIb clade with a divergence of 0.0018-0.0035. Isolates from B.1 lineage were the most predominant followed by B.1.2 and B.1.10.

Conclusion

This study will add integrated knowledge of the epidemiology, clinical features, and transmission of mpox.

Sub-lineage B.1.6 of hMPXV in a global context: Phylogeny and epidemiology

During the 2022 COVID-19 pandemic, monkeypox emerged as a significant threat to global health. The virus responsible for the disease, the human monkeypox virus (hMPXV), underwent various genetic changes, resulting in the emergence of over a dozen distinct lineages, which could be identified by only a small number of unique mutations. As of January 25, 2023, genomic information of hMPXV generated had reached 4632 accessions in the GISAID database. In this study, we aimed to investigate the epidemiological and phylogenetic characteristics of the B.1.6 sub-lineage of hMPXV in Peru, compared with other circulating sub-lineages during the global outbreak. The B.1.6 sub-lineage, characterized by the 111029G>A mutation, was estimated to have emerged in June 2022 and was found mainly in Peru. Most cases (95.8%) were men with an average age of 33 years, and nearly half of the patients had HIV, of whom only 77.35% received antiretroviral therapy. Our findings revealed that the B.1.6, B.1.4, and B.1.2 sub-lineages were well represented and had a higher number of mutations despite having the lowest media substitution rates per site per year. Moreover, it was estimated that B.1.2 and B.1.4 appeared in February 2022 and were the first two sub-lineages to emerge. A mutation profile was also obtained for each sub-lineage, reflecting that several mutations had a pattern similar to the characteristic mutation. This study provides the first estimation of the substitution rate and ancestry of each monkeypox sub-lineage belonging to the 2022 outbreak. Based on our findings, continued genomic surveillance of monkeypox is necessary to understand better and track the evolution of the virus.

Mpox: an updated review of dermatological manifestations in the current outbreak

Mpox is a disease caused by a double-stranded DNA orthopoxvirus discovered in 1958. In 2022, an outbreak on an unprecedented scale marked its transition from neglected, zoonotic disease circulating almost exclusively within African borders to sexually transmitted infection (STI) of international concern. Although phylogenetic evidence suggests progressive evolution from the strain associated with the 2018 outbreak in Nigeria, epidemiological links with previous cases have still not been completely elucidated. Clinically, mpox presents with systemic symptoms, such as fever, headache, malaise and a characteristic cutaneous eruption, similar to that of cognate viruses (e.g. smallpox). Mpox pseudopustules evolve through several stages, including umbilication and crusting, and resolve in the span of 2-3 weeks. The hallmarks that set the 2022 outbreak apart from classic mpox were a disproportionate number of cases occurring in men who have sex with men, an often localized cutaneous picture and a significant burden in terms of concomitant STIs. Investigations into the disease pathogenesis, related immune response, clinical and dermoscopic features, in addition to studies aimed at defining novel management strategies, have advanced mpox knowledge considerably. Herein, recent findings on mpox are reviewed, with a keen focus on dermatological manifestations and their implications in the current diagnostic scenario, reinforcing the pivotal role of dermatologists in managing suspect cases and preventing further spread of the contagion.

Awareness and acceptability of monkeypox vaccine in men who have sex with men

Background/aim

To determine the knowledge about and acceptance level of monkeypox vaccine in men who have sex with men (MSM).

Materials and methods

A 14-item questionnaire, developed by the European Centers for Disease Control (ECDC), was presented online to MSM, aged ≥18 years old, via smartphone applications (Grindr and Hornet), between June 30th and August 12th, 2022.

Results

Of the 737 participants who completed the survey, 678 were born in Türkiye and 59 were migrants/visitors born in different countries. All of the participants were living in Türkiye. The median age was 31 (range 18-68) years. Overall, 21.9% were HIV-positive, 94.9% were using antiretroviral therapy (ART), 3.9% reported using preexposure prophylaxis (PrEP), 9.9% had been diagnosed with a sexually transmitted infection (STI) in the past 12 months, and 10.1% reported using chemicals during sexual intercourse in the past three months.Participants aged 45-54 were significantly more concerned about being treated differently due to monkeypox than those in the other age groups (p = 0.038). Compared to the participants who were HIV-negative, those who were HIV-positive were significantly more worried about acquiring monkeypox (34.1% were very worried and 43.6% were worried, p = 0.033), were more likely to definitely or probably get vaccinated if offered (67.6% and 80.6%, respectively, p = 0.002), and were more concerned about being exposed to different attitudes due to monkeypox (37.0% and 53.3%, respectively, p < 0.01). Among those using ART, 82.3% and 50.0% reported that they would definitely or probably get vaccinated if offered, respectively (p = 0.046). There were no significant differences between groups for the remaining parameters.

Conclusion

Despite the low level of knowledge about monkeypox, the majority of the participants reported that they believed in the vaccine's efficacy. Those who were HIV-positive were particularly more concerned about monkeypox and were more willing to protect themselves compared to those who were HIV-negative.

Mpox: a review of laboratory detection techniques

Mpox (formerly monkeypox) is a zoonotic disease caused by monkeypox virus (MPXV), which, like smallpox, is characterised by skin rashes. While the world is currently grappling with the coronavirus disease 2019 pandemic, the appearance of MPXV has presented a global threat and raised concerns worldwide. Since May 2022, MPXV has spread rapidly in non-endemic mpox areas. As of 27 June 2023, the virus has spread to more than 112 countries and regions, with over 88,060 laboratory-confirmed cases and 147 deaths. Thus, measures to control the mpox epidemic are urgently needed. As the principal methods for identifying and monitoring mpox, laboratory detection techniques play an important role in mpox diagnosis. This review summarises the currently-used laboratory techniques for MPXV detection, discusses progress in improving these methods, and compares the benefits and limitations of various diagnostic detection methods. Currently, nucleic acid amplification tests, such as the polymerase chain reaction, are the most commonly used. Immunological methods have also been applied to diagnose the disease, which can help us discover new features of MPXV, improve diagnostic accuracy, track epidemic trends, and guide future prevention and control strategies, which are also vital for controlling mpox epidemics. This review provides a resource for the scientific community and should stimulate more research and development in alternative diagnostics to be applied to this and future public health crises.

Design, evaluation, and immune simulation of potentially universal multi-epitope mpox vaccine candidate: focus on DNA vaccine

Monkeypox (mpox) is a zoonotic infectious disease caused by the mpox virus. Mpox symptoms are similar to smallpox with less severity and lower mortality. As yet mpox virus is not characterized by as high transmissibility as some severe acute respiratory syndrome 2 (SARS-CoV-2) variants, still, it is spreading, especially among men who have sex with men (MSM). Thus, taking preventive measures, such as vaccination, is highly recommended. While the smallpox vaccine has demonstrated considerable efficacy against the mpox virus due to the antigenic similarities, the development of a universal anti-mpox vaccine remains a necessary pursuit. Recently, nucleic acid vaccines have garnered special attention owing to their numerous advantages compared to traditional vaccines. Importantly, DNA vaccines have certain advantages over mRNA vaccines. In this study, a potentially universal DNA vaccine candidate against mpox based on conserved epitopes was designed and its efficacy was evaluated via an immunoinformatics approach. The vaccine candidate demonstrated potent humoral and cellular immune responses in silico, indicating the potential efficacy in vivo and the need for further research.

Human monkeypox: history, presentations, transmission, epidemiology, diagnosis, treatment, and prevention

Human monkeypox is a zoonotic infection that is similar to the diseases caused by other poxviruses. It is endemic among wild rodents in the rainforests of Central and Western Africa, and can be transmitted via direct skin contact or mucosal exposure to infected animals. The initial symptoms include fever, headache, myalgia, fatigue, and lymphadenopathy, the last of which is the main symptom that distinguishes it from smallpox. In order to prevent and manage the disease, those who are infected must be rapidly diagnosed and isolated. Several vaccines have already been developed (e.g., JYNNEOS, ACAM2000 and ACAM3000) and antiviral drugs (e.g., cidofovir and tecovirimat) can also be used to treat the disease. In the present study, we reviewed the history, morphology, clinical presentations, transmission routes, diagnosis, prevention, and potential treatment strategies for monkeypox, in order to enable health authorities and physicians to better deal with this emerging crisis.

Detection of Monkeypox Cases Based on Symptoms Using XGBoost and Shapley Additive Explanations Methods

The monkeypox virus poses a novel public health risk that might quickly escalate into a worldwide epidemic. Machine learning (ML) has recently shown much promise in diagnosing diseases like cancer, finding tumor cells, and finding COVID-19 patients. In this study, we have created a dataset based on the data both collected and published by Global Health and used by the World Health Organization (WHO). Being entirely textual, this dataset shows the relationship between the symptoms and the monkeypox disease. The data have been analyzed, using gradient boosting methods such as Extreme Gradient Boosting (XGBoost), CatBoost, and LightGBM along with other standard machine learning methods such as Support Vector Machine (SVM) and Random Forest. All these methods have been compared. The research aims to provide an ML model based on symptoms for the diagnosis of monkeypox. Previous studies have only examined disease diagnosis using images. The best performance has belonged to XGBoost, with an accuracy of 1.0 in reviews. To check the model's flexibility, k-fold cross-validation is used, reaching an average accuracy of 0.9 in 5 different splits of the test set. In addition, Shapley Additive Explanations (SHAP) helps in examining and explaining the output of the XGBoost model.

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 systematic review to identify novel clinical characteristics of monkeypox virus infection and therapeutic and preventive strategies to combat the virus

Since May 2022, there has been a global increase in the number of Mpox virus (MPXV) cases in countries that were previously considered non-endemic. In July 2022, the World Health Organization (WHO) declared this outbreak a public health emergency of international concern. The objective of this systematic review is to examine the novel clinical features of Mpox and to assess the available treatment options for managing the disease in patients who are afflicted with it. We conducted a systematic search in several databases, including PubMed, Google Scholar, Cochrane Library, and the grey literature, from May 2022 to February 2023. We identified 21 eligible studies, which included 18,275 Mpox cases, for final qualitative analysis. The majority of cases were reported in men who have sex with men (MSM) and immunocompromised individuals with HIV (36.1%). The median incubation period was 7 days (IQR: 3-21). The novel clinical manifestations include severe skin lesions on the palms, oral and anogenital regions, as well as proctitis, penile edema, tonsillitis, ocular disease, myalgia, lethargy, and sore throat, without any preceding prodromal symptoms or systemic illness. In addition, fully asymptomatic cases were documented, and various complications, including encephalomyelitis and angina, were noted. Clinicians must be familiar with these novel clinical characteristics, as they can aid in testing and tracing such patients, as well as asymptomatic high-risk populations such as heterosexuals and MSM. In addition to supportive care, currently, there are several effective prophylactic and treatment strategies available to combat Mpox, including the vaccines ACAM2000 and MVA-BN7, as well as the immunoglobulin VIGIV and the antivirals tecovirimat, brincidofovir, and cidofovir against severe Mpox infection.

Clinical Performance Evaluation of a Rapid Real-Time PCR Assay for Monkeypox Diagnosis: a Retrospective and Comparative Study

In an increasingly globalized and interconnected world, the outbreak of an infectious disease in one country can become a worrying health emergency for the whole world. A current example is the 2022 monkeypox virus (mpox) outbreak affecting multiple areas across the world. In this context, strategies to interrupt transmission as soon as possible by identifying cases, clusters, and sources of infection should be developed around the world to prevent these crises. The aim of this retrospective and collaborative study was to perform external clinical validation of the VIASURE monkeypox virus real-time PCR detection kit (CerTest Biotec, Spain) with ready-to-use reagents designed for the rapid detection of mpox. A total of 165 samples with suspected infection were used for this analysis. The standard procedures of the clinical microbiology laboratory of the Miguel Servet University Hospital, using the RealStar Orthopoxvirus PCR kit v1.0 (Altona Diagnostics) and bidirectional Sanger sequencing (STAB VIDA, Caparica, Portugal), were considered reference techniques. Furthermore, a subset of 67 mpox-negative samples and 13 mpox-positive samples were routinely tested for clinical diagnosis of other rash/ulcerative pathologies. Accuracy testing resulted in appropriate clinical validation values, as follows: sensitivity, 1 (95% confidence interval [CI], 0.97 to 1); specificity, 1 (95% CI, 0.98 to 1); positive predictive value, 1 (95% CI, 0.93 to 1); negative predictive value, 1 (95% CI, 0.95 to 1). The strength of agreement between assays was almost perfect. The added value is the useful support for the specific diagnosis of mpox infections due to the diagnostic specificity data obtained. IMPORTANCE Given that a large number of mpox outbreaks have been reported worldwide since 2022 in countries in which the disease is not endemic, the main concern for clinicians and global health systems should be to develop effective, available, and easy-to-implement diagnostic strategies to interrupt mpox transmission as soon as possible. This retrospective study demonstrates the satisfactory clinical parameters of a commercially available molecular diagnostic kit for routine testing for mpox in clinical diagnostic laboratories.

Comparative evaluation of the clinical presentation and epidemiology of the 2022 and previous Mpox outbreaks: a rapid review and meta-analysis

BACKGROUND

In 2022, there were outbreaks of Mpox where the disease is not endemic. We summarised and compared the findings from published observational studies on the clinical presentation and epidemiology of the 2022 and previous outbreaks of Mpox.

METHODS

We registered a review protocol with the Open Science Framework (osf.io/j3kb7). We searched MEDLINE, Embase, CENTRAL, CINAHL and Scopus databases, and relevant websites up to August 30, 2022. Retrieved literature citations were screened for eligibility, and summary clinical presentation and epidemiological data from the included studies were pooled, when possible, using an inverse variance, random-effects model.

RESULTS

Seventy-nine studies met the eligibility. Irrespective of outbreak, fever, headache, myalgia, lymphadenopathy, pleomorphic skin lesions, oral lesions, and sore throat were potentially highly relevant Mpox manifestations, while conjunctivitis, cough, and possibly reactivation of varicella zoster virus may be part of the clinical presentation. The mean incubation period for the 2022 outbreaks was 7.4 d (6.4-8.4 d, I² 64.2%; 4 studies: 270 cases) and for previous outbreaks, 12.9 d (10.4-15.5 d; one study: 31 cases), p < .001. None of the male cases from previous outbreaks was reported to have sex with men (MSM) whereas almost all reported male cases from the 2022 outbreak were MSM. Concomitant sexually transmitted infections and perianal lesions were reported only among male cases from the 2022 outbreak, with the cases mostly presenting with genital lesions.

CONCLUSIONS

The 2022 Mpox outbreaks appear to be mostly among MSM and have a lower incubation period compared with previous outbreaks.Key messages79 studies met the review's inclusion criteria.The 2022 Mpox outbreaks appear to have shorter incubation period compared with previous outbreaks.Established clinical presentation of Mpox includes fever, headache, myalgia, lymphadenopathy, pleomorphic skin lesions, oral lesions, and sore throat.Almost all reported cases from the 2022 Mpox outbreaks were men who had sex with men (MSM).Concomitant sexually transmitted infections and perianal lesions were only reported among cases from the 2022 Mpox outbreaks.A significantly higher proportion of Mpox cases from the 2022 outbreaks had genital lesions compared with cases from previous outbreaks.The 2022 Mpox outbreaks appear to be mostly among MSM.

Design peptide and multi-epitope protein vaccine candidates against monkeypox virus using reverse vaccinology approach: an in-silico study

Monkeypox is a zoonotic virus that has recently affected different countries worldwide. On July 23, 2022, the WHO declared the outbreak of monkeypox as a public health emergency of international concern. Surveillance studies conducted in Central Africa in the 1980s and later during outbreaks in the same region showed smallpox vaccines to be clinically somewhat effective against Monkeypox virus. However, there is no specific vaccine against this virus. This research used bioinformatics techniques to establish a novel multi-epitope vaccine candidate against Monkeypox that can induce a strong immune response. Five well-known antigenic proteins (E8L, A30L, A35R, A29L, and B21R) of the virus were picked and assessed as possible immunogenic peptides. Two suitable peptide candidates were selected according to bio-informatics analysis. Based upon in silico evaluation, two multi-epitope vaccine candidates (ALALAR and ALAL) were built with rich-epitope domains consisting of high-ranking T and B-cell epitopes. After predicting and evaluating the 3D structure of the protein candidates, the most efficient 3D models were considered for docking studies with Toll-like receptor 4 (TLR4) and the HLA-A * 11:01, HLA-A*01:01, HLA-A*02:01, HLA-A*03:01, HLA-A*07:02, HLA-A*15:01, HLA-A*30:01 receptors. Subsequently, molecular dynamics (MD) simulation of up to 150 nanoseconds was employed to assess the durability of the interaction of the vaccine candidates with immune receptors. MD studies showed that M5-HLA-A*11:01, ALAL-TLR4, and ALALAR-TLR4 complexes were stable during simulation. Analysis of the in silico outcomes indicates that the M5 peptide and ALAL and ALALAR proteins may be suitable vaccine candidates against the Monkeypox virus.Communicated by Ramaswamy H. Sarma.

Development of a Multi-Epitope Universal mRNA Vaccine Candidate for Monkeypox, Smallpox, and Vaccinia Viruses: Design and In Silico Analyses

Notwithstanding the presence of a smallpox vaccine that is effective against monkeypox (mpox), developing a universal vaccine candidate against monkeypox virus (MPXV) is highly required as the mpox multi-country outbreak has increased global concern. MPXV, along with variola virus (VARV) and vaccinia virus (VACV), belongs to the Orthopoxvirus genus. Due to the genetic similarity of antigens in this study, we have designed a potentially universal mRNA vaccine based on conserved epitopes that are specific to these three viruses. In order to design a potentially universal mRNA vaccine, antigens A29, A30, A35, B6, and M1 were selected. The conserved sequences among the three viral species-MPXV, VACV, and VARV-were detected, and B and T cell epitopes containing the conserved elements were used for the design of the multi-epitope mRNA construct. Immunoinformatics analyses demonstrated the stability of the vaccine construct and optimal binding to MHC molecules. Humoral and cellular immune responses were induced by immune simulation analyses. Eventually, based on in silico analysis, the universal mRNA multi-epitope vaccine candidate designed in this study may have a potential protection against MPXV, VARV, and VACV that will contribute to the advancement of prevention strategies for unpredictable pandemics.

Global transmission of monkeypox virus-a potential threat under the COVID-19 pandemic

Monkeypox virus (MPXV) cases have increased dramatically worldwide since May 2022. The Atlanta Center for Disease Control and Prevention (Atlanta CDC) had reported a total of 85,922 cases as of February 20^th, 2023. During the COVID-19 pandemic, MPXV has emerged as a potential public threat. MPXV transmission and prevalence must be closely monitored. In this comprehensive review, we explained the basic characteristics and transmission routes of MPXV, individuals susceptible to it, as well as highlight the impact of the behavior of men who have sex with men (MSM) and airline traveling on recent outbreaks of MPXV. We also describe the clinical implications, the prevention of MPXV, and clinical measures of viral detection.

Adrenal Insufficiency Secondary to Monkeypox Infection: A Case Report

Our case report confirms adrenal insufficiency following three weeks of monkeypox infection in an immunocompetent patient. As there is no specific treatment for monkeypox, steroid replacement therapy remains the cornerstone of managing adrenal insufficiency. By highlighting the importance of early identification and tracing in our case report, we contribute to the growing body of knowledge on monkeypox and emphasize the importance of identifying adrenal insufficiency and other complications like meningoencephalitis, prompting a significant early intervention that can help manage these complications effectively, potentially improving patient outcomes. In addition, understanding disease progression by tracing monkeypox cases provides valuable information on the disease's natural history, including the timeline and sequence of symptoms, associated complications, and outcomes, to avoid any small chance related to our lack of validated knowledge or incorrect assessment of the disease or the associated complications between an exposure and an effect in the target organs.

Overview of Diagnostic Methods, Disease Prevalence and Transmission of Mpox (Formerly Monkeypox) in Humans and Animal Reservoirs

Mpox-formerly monkeypox-is a re-emerging zoonotic virus disease, with large numbers of human cases reported during multi-country outbreaks in 2022. The close similarities in clinical symptoms that Mpox shares with many orthopoxvirus (OPXV) diseases make its diagnosis challenging, requiring laboratory testing for confirmation. This review focuses on the diagnostic methods used for Mpox detection in naturally infected humans and animal reservoirs, disease prevalence and transmission, clinical symptoms and signs, and currently known host ranges. Using specific search terms, up to 2 September 2022, we identified 104 relevant original research articles and case reports from NCBI-PubMed and Google Scholar databases for inclusion in the study. Our analyses observed that molecular identification techniques are overwhelmingly being used in current diagnoses, especially real-time PCR (3982/7059 cases; n = 41 studies) and conventional PCR (430/1830 cases; n = 30 studies) approaches being most-frequently-used to diagnose Mpox cases in humans. Additionally, detection of Mpox genomes, using qPCR and/or conventional PCR coupled to genome sequencing methods, offered both reliable detection and epidemiological analyses of evolving Mpox strains; identified the emergence and transmission of a novel clade 'hMPXV-1A' lineage B.1 during 2022 outbreaks globally. While a few current serologic assays, such as ELISA, reported on the detection of OPXV- and Mpox-specific IgG (891/2801 cases; n = 17 studies) and IgM antibodies (241/2688 cases; n = 11 studies), hemagglutination inhibition (HI) detected Mpox antibodies in human samples (88/430 cases; n = 6 studies), most other serologic and immunographic assays used were OPXV-specific. Interestingly, virus isolation (228/1259 cases; n = 24 studies), electron microscopy (216/1226 cases; n = 18 studies), and immunohistochemistry (28/40; n = 7 studies) remain useful methods of Mpox detection in humans in select instances using clinical and tissue samples. In animals, OPXV- and Mpox-DNA and antibodies were detected in various species of nonhuman primates, rodents, shrews, opossums, a dog, and a pig. With evolving transmission dynamics of Mpox, information on reliable and rapid detection methods and clinical symptoms of disease is critical for disease management.

Demographic, Epidemiologic, and Clinical Characteristics of Human Monkeypox Disease Pre- and Post-2022 Outbreaks: A Systematic Review and Meta-Analysis

(1) Background: In early May 2022, an increasing number of human monkeypox (mpox) cases were reported in non-endemic disparate regions of the world, which raised concerns. Here, we provide a systematic review and meta-analysis of mpox-confirmed patients presented in peer-reviewed publications over the 10 years before and during the 2022 outbreak from demographic, epidemiological, and clinical perspectives. (2) Methods: A systematic search was performed for relevant studies published in Pubmed/Medline, Embase, Scopus, and Google Scholar from 1 January 2012 up to 15 February 2023. Pooled frequencies with 95% confidence intervals (CIs) were assessed using the random or fixed effect model due to the estimated heterogeneity of the true effect sizes. (3) Results: Out of 10,163 articles, 67 met the inclusion criteria, and 31 cross-sectional studies were included for meta-analysis. Animal-to-human transmission was dominant in pre-2022 cases (61.64%), but almost all post-2022 reported cases had a history of human contact, especially sexual contact. The pooled frequency of MSM individuals was 93.5% (95% CI 91.0-95.4, I2: 86.60%) and was reported only in post-2022 included studies. The male gender was predominant in both pre- and post-2022 outbreaks, and the mean age of confirmed cases was 29.92 years (5.77-41, SD: 9.38). The most common clinical manifestations were rash, fever, lymphadenopathy, and malaise/fatigue. Proctalgia/proctitis (16.6%, 95% CI 10.3-25.6, I2: 97.76) and anal/perianal lesions (39.8%, 95% CI 30.4-49.9, I2: 98.10) were the unprecedented clinical manifestations during the 2022 outbreak, which were not described before. Genitalia involvement was more common in post-2022 mpox patients (55.6%, 95% CI 51.7-59.4, I2: 88.11). (4) Conclusions: There are speculations about the possibility of changes in the pathogenic properties of the virus. It seems that post-2022 mpox cases experience a milder disease with fewer rashes and lower mortality rates. Moreover, the vast majority of post-2022 cases are managed on an outpatient basis. Our study could serve as a basis for ongoing investigations to identify the different aspects of previous mpox outbreaks and compare them with the current ones.

Bioinformatic approaches to draft the viral genome sequence of Canary Islands cases related to the multicountry mpox virus 2022-outbreak

On July 23, 2022, monkeypox disease (mpox) was declared a Public Emergency of International Concern (PHEIC) by the World Health Organization (WHO) due to a multicountry outbreak. In Europe, several cases of mpox virus (MPXV) infection related to this outbreak were detected in the Canary Islands (Spain). Here we describe the combination of viral DNA sequencing and bioinformatic approaches, including methods for de novo genome assembly and short- and long-read technologies, used to reconstruct the first MPXV genome isolated in the Canary Islands on the 31^st of May 2022 from a male adult patient with mild symptoms. The same sequencing and bioinformatic approaches were then validated with three other positive cases of MPXV infection from the same mpox outbreak. We obtained the best results using a reference-based approach with short reads, evidencing 46-79 nucleotide variants against viral sequences from the 2018-2019 mpox outbreak and placing the viral sequences in the new B.1 sublineage of clade IIb of the MPXV classification. This study of MPXV demonstrates the potential of metagenomics sequencing for rapid and precise pathogen identification.

Evidence synthesis of Chinese medicine for monkeypox: Suggestions from other contagious pox-like viral diseases

Background: Monkeypox, a zoonotic disease caused by an Orthopoxvirus, presents an etiology similar to smallpox in humans. Currently, there are no licensed treatments for human monkeypox, so clear and urgent research on its prophylaxis and treatment is needed.

Objective: The purpose of this study was to explore the evidence of Chinese medicine for contagious pox-like viral diseases and provide suggestions for the multi-country outbreak management of monkeypox.

Methods: The review was registered on INPLASY (INPLASY202270013). Ancient classics in China and clinical trials involving randomized controlled trials , non-RCTs, and comparative observational studies of CM on the prevention and treatment of monkeypox, smallpox, measles, varicella, and rubella were retrieved from the Chinese Medical Code (fifth edition), Database of China Ancient Medicine, PubMed, the Cochrane Library, China National Knowledge Infrastructure, Chongqing VIP, Wanfang, Google Scholar, International Clinical Trial Registry Platform, and Chinese Clinical Trial Registry until 6 July 2022. Both quantitative and qualitative methods were applied to present the data collected.

Results: The use of CM to control contagious pox-like viral diseases was traced back to ancient Chinese practice cited in Huangdi’s Internal Classic, where the pathogen was recorded nearly two thousand years back. There were 85 articles (36 RCTs, eight non-RCTs, one cohort study, and 40 case series) that met the inclusion criteria, of which 39 studies were for measles, 38 for varicella, and eight for rubella. Compared with Western medicine for contagious pox-like viral diseases, CM combined with Western medicine showed significant improvements in fever clearance time (mean difference, −1.42 days; 95% CI, −1.89 to −0.95; 10 RCTs), rash/pox extinction time (MD, −1.71 days; 95% CI, −2.65 to −0.76; six RCTs), and rash/pox scab time (MD, −1.57 days; 95% CI, −1.94 to −1.19; five RCTs). When compared with Western medicine, CM alone could reduce the time of rash/pox extinction and fever clearance. Chinese herbal formulas, including modified Yinqiao powder, modified Xijiao Dihaung decoction, modified Qingjie Toubiao decoction, and modified Shengma Gegen decoction, were frequently applied to treat pox-like viral diseases and also showed significant effects in shortening the time of fever clearance, rash/pox extinction, and rash/pox scabs. Compared with Western medicine (placental globulin) or no intervention, eight non-randomized trials and observational studies on the prevention of contagious pox-like viral diseases showed a significant preventive effect of Leiji powder among high-risk populations.

Conclusion: Based on historical records and clinical studies of CM in managing contagious pox-like viral diseases, some botanical drugs could be an alternative approach for treating and preventing human monkeypox. Prospective, rigorous clinical trials are urgently needed to confirm the potential preventive and treatment effect of Chinese herbal formulas.

Systematic Review Registration: [https://inplasy.com/], identifier [INPLASY202270013].

The recent re-emergence of human monkeypox: Would it become endemic beyond Africa?

Viral outbreaks still become global health challenges, for instance, influenza A viruses, Japanese encephalitis, Ebola virus, Yellow fever, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Since 7 May 2022, another outbreak of monkeypox also has been reported in European countries and the United States. Meanwhile, the monkeypox virus is previously endemic only in the western and central parts of Africa. Monkeypox is a zoonotic disease, although the primary animal reservoir remains unknown. This article concisely reviews the monkeypox virus, its transmission, pathogenesis, and clinical manifestation, its changing global epidemiology before and during the current outbreak, and possible driving factors of the recent outbreak. Furthermore, we also discuss whether the monkeypox virus would become endemic beyond Africa. Even though the available data suggests that human-to-human transmission is currently happening and unconnected clusters exist, many efforts have been made to tackle this outbreak, such as active case detection, contact tracing, isolation, and postexposure vaccination.

Mpox (Monkeypox) Presenting as Cervical and Vulvar Disease

BACKGROUND

Since the beginning of the current mpox (formerly "monkeypox") outbreak in May 2022, 23,465 confirmed cases of monkeypox virus infection have been reported in Europe; women represent less than 1% of these cases. Mpox lesions are found with greater frequency in the genital area, and, in women, have been described primarily in the vulva.

CASE

We present a case of monkeypox virus infection in a 28-year-old woman confirmed by polymerase chain reaction testing, in which the only clinical manifestation was the appearance of concomitant lesions in the cervix and the vulva, with no other clinical features. No other sexual transmitted diseases were found. The lesions disappeared spontaneously in 2 weeks.

CONCLUSION

Mpox lesions can affect the cervix; thus, recognition by gynecologists is important. Given the current epidemic outbreak, correct identification is essential to help control disease transmission.

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.