Oral lesions in patients with human monkeypox: A systematic scoping review

Surgical Care in the Era of Mpox Clade I: A Review and Call for Preparedness

The Mpox virus, formerly known as Monkeypox, was declared a Public Health Emergency of International Concern in July 2022 due to its rapid global spread. By 2024, the more virulent and fatal Clade Ib variant had reached the United States. While Mpox typically presents with a self-limited rash, severe manifestations requiring surgical intervention have become increasingly prevalent, necessitating heightened awareness and preparedness among surgeons.This narrative review, specifically targeting surgeons, provides a comprehensive summary of the current data on the epidemiology, pathophysiology, perioperative considerations, and surgical management of Mpox-related conditions. It outlines essential hospital protocols and perioperative precautions to mitigate nosocomial spread, drawing useful parallels with measures established for COVID-19. It also addresses Mpox-related surgical pathologies, including colorectal abscesses, cutaneous scarring, facial lesions, and ocular complications, detailing management strategies for each.Our findings emphasize the need for rigorous infection control measures, early recognition of surgical indications, and interdisciplinary coordination to optimize patient outcomes, especially since Mpox is most readily transmitted among immunocompromised individuals, such as those who have undergone solid organ transplants. The virus primarily spreads through sexual transmission and contact with infected skin lesions, necessitating standardized hospital protocols to minimize its spread, particularly in operating rooms. Colorectal manifestations often require surgical drainage, with colostomy being necessary in severe cases, while ophthalmic manifestations demand prompt and aggressive management to preserve vision. Airway management and anesthetic planning are also critical considerations in cases involving oropharyngeal Mpox lesions.This review highlights the urgent need for ongoing documentation and research to refine surgical management protocols for Mpox, enhancing preparedness for future outbreaks. The complexity and severity of Mpox-related surgical pathologies underscore the necessity for further studies to refine management strategies, develop innovative treatments, and improve patient outcomes. Future research should aim to deepen our understanding of Mpox pathophysiology and optimize protocols to ensure safe and effective care for affected patients. This is essential in an era marked by the threat of emerging infectious diseases and the lessons learned from recent global health crises.

Mpox and oral health among children in Africa

Much like it has historically, recent mpox outbreaks in Africa have significantly affected children and highlight major public health challenges, including oral healthcare in pandemic responses. The global 2022 outbreak saw an unprecedented number of mpox cases outside Africa, however children were a minority, constituting less than 2%, with the vast majority of cases reported among adult men who have sex with men. However, African countries continue to report high proportions of pediatric mpox cases, particularly Clade 1 in Burundi, the DRC, and the Congo, and Clade 2 in Nigeria. Oral manifestations of mpox such as ulcers and lesions on the lips and tongue are common and can precede skin rash, making early diagnosis challenging, especially in low-resource settings. Misdiagnosis is also a risk due to the similarity of mpox oral lesions to common pediatric exanthems and enanthems. Oral and other manifestations so mpox among affected children in Africa may be worsened due to delayed treatment and increased morbidity from high rates of malnutrition and immunosuppression, including due to HIV. This paper explores the implications of mpox on the oral health of children in Africa, emphasizing the need for improved surveillance, early detection, and the integration of the mpox response into existing child health programs. Child-focused clinical and public health research, healthcare worker training, and accessible, child-friendly diagnostic tools will be crucial for mitigating the impact of mpox on this vulnerable population.

Use of cidofovir in a patient with severe mpox and uncontrolled HIV infection

A 48-year-old man with poorly controlled HIV presented with severe human monkeypox virus (hMPXV) infection, having completed 2 weeks of tecovirimat at another hospital. He had painful, ulcerating skin lesions on most of his body and oropharyngeal cavity, with subsequent Ludwig's angina requiring repeated surgical interventions. Despite commencing a second, prolonged course of tecovirimat, he did not objectively improve, and new lesions were still noted at day 24. Discussion at the UK National Health Service England High Consequence Infectious Diseases Network recommended the use of 3% topical and then intravenous cidofovir, which was given at 5 mg/kg; the patient made a noticeable improvement after the first intravenous dose. He received further intravenous doses at 7 days and 21 days after the dose and was discharged at day 52. Cidofovir is not licensed for use in treatment of hMPXV infection. Data for cidofovir use in hMPXV are restricted to studies in animals. Four other documented cases of cidofovir use against hMPXV have been reported in the USA in 2022, but we present its first use in the UK. The scarcity of studies into the use of cidofovir in this condition clearly shows the need for robust studies to assess efficacy, optimum dosage, timing, and route of administration.

Monkeypox: A New Challenge for Global Health System?

The COVID-19 pandemic, starting in 2020, has presented a major challenge in terms of early diagnosis and the subsequent containment and management of severe cases. The spread of viruses such as monkeypox in non-endemic countries is now creating new difficulties for healthcare professionals. Proper case definition and clinical examination are crucial for the early identification of suspected cases. For this reason, we performed a review of the literature in order to report the first signs, which are useful for healthcare providers for early case identification. Since 2022 to date, 86,930 laboratory-confirmed cases and 1051 probable cases have been reported worldwide, and of these, 116 were fatal cases and, for the first time, most of the cases were registered in countries that have not historically reported monkeypox and that lack direct or immediate epidemiological links to areas of West or Central Africa where the disease is endemic. Patients with Monkeypox experience prodromal symptoms, such as fever, fatigue, headache, muscle aches, and a rash after an incubation period of 5-21 days. The disease is usually self-limiting within 2-4 weeks but can lead to complications, such as pneumonia, encephalitis, kidney injury, and myocarditis in children, pregnant individuals, and those with weakened immune systems. The case-fatality ratio is between 1 and 10%. Today, prevention campaigns and the control of human monkeypox are the best weapons to prevent infection and stop transmission. Prevention strategies, such as avoiding contact with sick or dead animals, and the proper preparation of all foods containing animal meat or parts, should be adopted. Furthermore, close contact with infected people or contaminated materials should be avoided to prevent human-to-human transmission.