A monkeypox virus infection mimicking primary syphilis

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.

Epidemiological and clinical differences of confirmed and discarded Mpox cases on the 2022 Chilean outbreak

Objectives

To improve Mpox diagnosis by identifying distinctive symptoms in confirmed vs discarded cases due to outdated case definition.

Methods

This is a case-control study conducted using data from the Institute of Public Health database, encompassing all suspected cases analyzed by real-time polymerase chain reaction between June 1 and September 30, 2022. We calculated means, frequencies, performed Fisher's test, and computed odds ratios (OR) using RStudio and Microsoft Excel.

Results

Among 1415 suspected Mpox cases, 87% were men aged 30-39 with exanthema. Confirmed cases had higher rates of lymphadenopathy (31% vs 12%), fever (42% vs 29%), myalgia (35% vs 25%), and specific lesions: pustules (36% vs 27%), scabs (25% vs 17%), and umbilicated lesions (24% vs 7%) (P <0.05). Key risk factors for Mpox included contact with a positive case (OR 2.33), multiple sexual partners (OR 3.52), and male gender (OR 29.93).

Conclusion

The symptomatology of confirmed Mpox cases closely aligns with that reported in the current outbreak. The primary risk factors identified include prior contact with another positive case, having multiple sexual partners, and male gender. However, to facilitate a more complete analysis, more evidence needs to be investigated.

Primary syphilis, an extremely uncommon cause of acute-onset phimosis

We present a case of phimosis in the context of primary syphilis with a preputial chancre. An accurate diagnosis after an appropriate examination and patient history allowed conservative treatment with antibiotics and the avoidance of circumcision in this patient.

Monkeypox (Mpox): Evolution of Transmission and Comprehensive Review

The human monkeypox (mpox) virus is an orthopox virus that can be transmitted to humans. Though the disease has been endemic in Africa, the recent mpox outbreak since May 2022. We attempted to examine differences between the endemic form of mpox and the current outbreak. Review of electronic medical database with relevant keywords. The current outbreak of mpox has disproportionately impacted the gay, bisexual and other men who have sex with men (MSM) community. This is also the first time that widespread semen testing has turned up evidence of mpox viral deoxyribonucleic acid (DNA). Cases in the present outbreak are more likely to affect adults, involve the genitalia, and have no prodrome. Close diagnostic differentials include varicella and hand-foot-mouth disease. The disease is usually self-limiting; though secondary infections, anorectal pain, pharyngitis, ocular lesions and rarely, renal injury and myocarditis may occur. This review focuses primarily on the novel clinical characteristics and emerging sexual transmission route of the mpox virus, which, although unconfirmed, appears extremely likely as the route of spread. Dermatologists have an important role in this health emergency, as early diagnosis can cause a significant reduction in disease transmission.

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.

Adverse pregnancy outcomes and associated risk factors among pregnant women with syphilis during 2013-2018 in Hunan, China

Objective

To investigate the adverse pregnancy outcomes and associated risk factors among pregnant women with syphilis.

Design

Pregnant women with syphilis in the registry for the prevention of mother-to-child transmission of AIDS, syphilis and hepatitis B in Hunan Province, China, from January 1, 2013 to December 31, 2018 were included in the study.

Results

Among the 14,219 pregnant women with syphilis, 11,346 had definite pregnancy outcomes and were in singleton pregnancy. The risk factors related to adverse pregnancy outcomes include the age of pregnant women with syphilis <20 years old (aOR = 1.274, 95% CI: 1.088-1.493) or ≥ 35 years old (aOR = 1.402, 95% CI: 1.167-1.686), not married (aOR = 1.855, 95% CI: 1.453-2.367), initial syphilis detection in the late pregnancy (aOR = 1.266, 95% CI: 1.032-1.555), diagnosis of syphilis in the late pregnancy (aOR = 5.806, 95% CI: 1.796-18.770), diagnosis of syphilis during labor (aOR = 4.102, 95% CI: 1.263-13.330), husband/sexual partner infected with syphilis (aOR = 1.222, 95% CI: 1.068-1.398), untreated (aOR = 6.756, 95% CI: 5.586-8.197), and nonstandard medication (aOR = 3.300, 95% CI: 2.841-3.846).

Conclusion

The prevalence of adverse pregnancy outcomes among pregnant women with syphilis in Hunan Province, China from 2013 to 2018 was relatively high. The adverse pregnancy outcomes associated with syphilis could be reduced by early detection and standard treatment of syphilis for pregnant women and their husbands/sexual partners.

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.

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.

Syphilis

Syphilis is an important public health problem in the U.S. and many high-income nations. The rates of syphilis continue to increase and there is an urgent need for medical providers of a variety of backgrounds to recognize this disease. In this review, we cover the key clinical findings of syphilis and provide an overview of the diagnosis and management of this disease in adults.

Monkeypox: a new global health emergency with predominant dermatological manifestations

Monkeypox is a zoonotic virus belonging to the Orthopoxvirus genus. Previously endemic to Africa, outbreaks have been reported from all over the world, the largest of which is currently ongoing. Dermatologists are principally involved in recognition and diagnosis of the infection. This narrative review primarily focuses on clinical manifestations and highlights the unique epidemiological features of current outbreak. Lesions observed during the current outbreak lack the evolution described in endemic disease. Polymorphic lesions are common and may be confined to anogenital area. Onset of "prodromal" symptoms may coincide with onset of skin rash, and these may be altogether absent. Mortality rates observed are low. The exanthem should be differentiated from other infections such as herpes, molluscum contagiosum, smallpox, and other poxvirus infections. Presentation as an isolated genital lesion warrants differentiation from syphilis, chancroid, and other sexually transmitted diseases. Close intimate contact during sexual encounters is the primary mode of transmission, and other coexisting sexually transmitted infections are frequently diagnosed.

Detection of Monkeypox Virus according to The Collection Site of Samples from Confirmed Cases: A Systematic Review

Due to the rapid evolution of the monkeypox virus, the means by which the monkeypox virus is spread is subject to change. Therefore, the present study aims to analyze the detection of the monkeypox virus according to the collection site of samples from confirmed monkeypox cases. A systematic literature review was performed using PubMed, Scopus, Web of Science, and Embase databases until 5 October 2022. A total of 1022 articles were retrieved using the search strategy. After removing duplicates (n = 566) and examining by title, abstract, and full text, 65 studies reporting monkeypox case reports were included with a detailed description of risk factors, sexually transmitted infections (STIs), site of monkeypox virus-positive specimens, location of skin lesions, and diagnostic test. A total of 4537 confirmed monkeypox cases have been reported, of which 98.72% of the cases were male with a mean age of 36 years, 95.72% had a sexual behavior of being men who have sex with men, and 28.1% had human immunodeficiency virus (HIV). The most frequent locations of lesions in patients diagnosed with monkeypox were: 42.85% on the genitalia and 37.1% in the perianal region. All confirmed monkeypox cases were diagnosed by reverse transcriptase polymerase chain reaction (RT-PCR), and the most frequent locations of samples collected for diagnosis that tested positive for monkeypox virus were: 91.85% from skin lesions, 20.81% from the oropharynx, 3.19% from blood, and 2.43% from seminal fluid. The disease course of the cases with monkeypox was asynchronous, with no severe complications, and most patients did not report specific treatment but simply followed a symptomatic treatment.

The evolving epidemiology of monkeypox virus

Monkeypox, caused by the monkeypox virus (MPXV), is a zoonotic disease endemic mainly in West and Central Africa. As of 27 September 2022, human monkeypox has occurred in more than 100 countries (mostly in non-endemic regions) and caused over 66,000 confirmed cases, which differs from previous epidemics that mainly affected African countries. Due to the increasing number of confirmed cases worldwide, the World Health Organization (WHO) has declared the monkeypox outbreak as a Public Health Emergency of International Concern on July 23, 2022. The international outbreak of human monkeypox represents a novel route of transmission for MPXV, with genital lesions as the primary infection, and the emergence of monkeypox in the current outbreak is also new, as novel variants emerge. Clinical physicians and scientists should be aware of this emerging situation, which presents a different scenario from previous outbreaks. In this review, we will discuss the molecular virology, evasion of antiviral immunity, epidemiology, evolution, and detection of MPXV, as well as prophylaxis and treatment strategies for monkeypox. This review also emphasizes the integration of relevant epidemiological data with genomic surveillance data to obtain real-time data, which could formulate prevention and control measures to curb this outbreak.