Monkeypox and HIV/AIDS: When the outbreak faces the epidemic

Mpox infection in animals: A systematic review and meta-analysis

Mpox is a zoonotic disease that became epidemic in multiple countries in 2022. There is a lack of published systematic reviews on natural animal infection due to Mpox. We performed a systematic literature review with meta-analysis to assess animal Mpox prevalence. We performed a random-effects model meta-analysis to calculate the pooled prevalence and 95% confidence interval (95%CI) for prevalence studies. After the screening, 15 reports were selected for full-text assessment and included in qualitative and quantitative analyses. Ten reports assessed Mpox infection by molecular or serological tests (n = 2680), yielding a pooled prevalence of 16.0% (95%CI: 3.0-29.0%) for non-human primates; 8.0% (95%CI: 4.0-12.0%) for rodents and 1.0% (95%CI: 0.0-3.0%) for shrews. Further studies in other animals are required to define the extent and importance of natural infection due to Mpox. These findings have implications for public human and animal health. OneHealth approach is critical for prevention and control.

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.

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.

Mpox in people living with HIV

PURPOSE OF REVIEW

The 2022 global outbreak of mpox disproportionally affected people with HIV (PWH). We review the data on the presentation, treatment, and prevention of mpox in PWH.

RECENT FINDINGS

Most PWH with mpox had a mild and self-limiting illness, no different to people without HIV. A higher rate of rectal symptoms has been reported among PWH and those with advanced HIV disease were at higher risk of severe disease, hospitalization, and death. Treatment with antivirals was widely used in hospitalized patients without any randomized control trial data to support its use and without any data specifically in PWH. Use of smallpox vaccines to prevent mpox is safe in PWH regardless of CD4+ cell count. There is limited data on efficacy in those with lower CD4+ cell count and on long-term protective efficacy.

SUMMARY

PWH should be offered vaccination against mpox in line with national guidelines. PWH should be individually risk-assessed for severe mpox, based on their CD4+ cell count and co-morbidities and ideally recruited into treatment trials to build an evidence base on efficacy. HIV and other sexually transmitted infection testing should be offered to all people diagnosed with mpox.

The Potential Relationship Between Cardiovascular Diseases and Monkeypox

Mpox, a novel epidemic disease, has broken out the period of coronavirus disease 2019 since May 2022, which was caused by the mpox virus. Up to 12 September 2023, there are more than 90,439 confirmed mpox cases in over 115 countries all over the world. Moreover, the outbreak of mpox in 2022 was verified to be Clade II rather than Clade I. Highlighting the significance of this finding, a growing body of literature suggests that mpox may lead to a series of cardiovascular complications, including myocarditis and pericarditis. It is indeed crucial to acquire more knowledge about mpox from a perspective from the clinical cardiologist. In this review, we would discuss the epidemiological characteristics and primary treatments of mpox to attempt to provide a framework for cardiovascular physicians.

Proctitis in patients with monkeypox infection: a single-center analysis of 42 consecutive cases from a multidisciplinary observational study on monkeypox proctitis

BACKGROUND

The current monkeypox (MP) virus outbreak was declared an international emergency in July 2022. The aim of this report is to describe our initial experience with patients with MP, focusing on proctitis.

METHODS

We conducted an observational study between 20 May and 31 July 2022, on patients with MP at a reference tertiary center in Madrid, Spain. A descriptive analysis on MP was performed, focusing on its characteristics, symptoms, diagnosis, and outcomes.

RESULTS

A total of 143 positive MP cases were diagnosed in our center; 42 of them [all male, median age 39 years (range: 22-57 years)] had proctitis (29.37%), and 3 patients (2.09%/MP total cases and 7.14%/MP proctitis) required surgical drainage of a perianal abscess.

CONCLUSIONS

General and digestive surgeons must be aware of the presence of proctological impairment and complications due to MP virus.

Epidemiological and Clinical Characteristics of Patients Admitted to a Secondary Hospital with Suspected MPOX Virus Infection: Is HIV Playing a Role?

MPOX (monkeypox) is a zoonotic viral disease, endemic in some Central and West African countries. However, in May 2022, cases began to be reported in non-endemic countries, demonstrating community transmission. Since the beginning of the outbreak, different epidemiological and clinical behaviors have been observed. We conducted an observational study at a secondary hospital in Madrid to characterize suspected and confirmed cases of MPOX epidemiologically and clinically. Besides the general descriptive analysis, we compared data between HIV-positive and HIV-negative subjects; 133 patients were evaluated with suspected MPOX, of which 100 were confirmed. Regarding positive cases, 71.0% were HIV positive, and 99.0% were men with a mean age of 33. In the previous year, 97.6% reported having sex with men, 53.6% used apps for sexual encounters, 22.9% practiced chemsex, and 16.7% went to saunas. Inguinal adenopathies were significantly higher in MPOX cases (54.0% vs. 12.1%, p < 0.001), as the involvement of genital and perianal area (57.0% vs. 27.3% and 17.0% vs. 1.0%, p = 0.006 and p = 0.082 respectively). Pustules were the most common skin lesion (45.0%). In HIV-positive cases, only 6.9% had a detectable viral load, and the mean CD4 count was 607.0/mm³. No significant differences were observed in the disease course, except for a greater tendency towards the appearance of perianal lesions. In conclusion, the MPOX 2022 outbreak in our area has been related to sexual intercourse among MSM, with no severe clinical cases nor apparent differences in HIV and non-HIV patients.

Human monkeypox coinfection with syphilis in an immunocompromised patient

Monkeypox is a viral zoonosis from the Poxviridae family that spreads at an unprecedented rate. It is transmitted through contact with skin lesions, respiratory droplets, body fluids, and sexual contact. The diverse presentation of the disease leads to misdiagnosis. Thus, clinicians should have a high index of suspicion, mainly with diseases with skin lesions. The most vulnerable group to developing this disease are individuals with risky sexual relationships, sexually transmitted infections, or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). To date, only one case of coinfection with the monkeypox virus, syphilis, and HIV has been reported; however, no cases have been revealed in the Mexican territory. Herein we describe an unusual case of syphilis-monkeypox coinfection in an immunocompromised patient; despite his coinfection, he had a favorable prognosis. Furthermore, we attach allusive pictures of the natural evolution of dermatological lesions.

Epidemiology, host range, and associated risk factors of monkeypox: an emerging global public health threat

Based on recent multiregional epidemiological investigations of Monkeypox (MPX), on 24 July 2022, the World Health Organization declared it a global public health threat. Retrospectively MPX was an ignored zoonotic endemic infection to tropical rainforest regions of Western and Central African rural communities until a worldwide epidemic in May 2022 verified the potential threat of monkeypox virus (MPXV) to be propagated across the contemporary world via transnational tourism and animal movements. During 2018-2022, different cases of MPX diagnosed in Nigerian travelers have been documented in Israel, the United Kingdom, Singapore, and the United States. More recently, on 27 September 2022, 66,000 MPX cases have been confirmed in more than 100 non-endemic countries, with fluctuating epidemiological footprinting from retrospective epidemics. Particular disease-associated risk factors fluctuate among different epidemics. The unpredicted appearance of MPX in non-endemic regions suggests some invisible transmission dynamic. Hence, broad-minded and vigilant epidemiological attention to the current MPX epidemic is mandatory. Therefore, this review was compiled to highlight the epidemiological dynamic, global host ranges, and associated risk factors of MPX, concentrating on its epidemic potential and global public health threat.

A cross-sectional survey of public knowledge of the monkeypox disease in Nigeria

The Monkeypox Disease (MPXD) gained attention due to its widened geographical distribution outside of Africa, Hence, a it was declared a global health emergency. The index case in Europe was from a Nigerian traveller. This study assessed public awareness and knowledge of the MPXD by conducting an online, cross-sectional survey of educated Nigerians. A total of 822 respondents were recruited using the snowball sampling method between the 16th to 29th of August 2022. More responses were retrieved from the Northeastern geopolitical region (30.1%, n=220) than other regions. Descriptive statistics revealed that 89% (n=731/822) of the study participants were aware of the MPXD but only 58.7% (n=429/731) of them had good knowledge of the disease with a mean knowledge score of 5.31±2.09. The main knowledge gaps were in the incubation period of the disease, the signs and symptoms, its mode of transmission, and preventive practices needed to curb the spread of the monkeypox virus (MPXV). Specifically, only 24.5% (n=179) of them knew that MPXV can be transmitted via sexual contact. Most of the study participants (79.2%, n=651) opined that we can prevent the occurrence of public health emergencies in the future. The multivariable logistic regression analysis revealed that of the socio-demographic variables, the male gender (OR: 1.69; 95% CI: 1.22,2.33); Ph.D. level education (1.44; 95% CI: 1.048,4.23); and being homosexual (OR:1.65; 95% CI: 1.07,3.78) were significantly associated with good knowledge of MPXD. Despite the varying prevalence across the country, the region of residence within Nigeria did not influence the knowledge of MPXD among the respondents. The knowledge gaps necessitate intensified public health risk communication with a focus on modes of transmission and the preventive measures needed to curb the spread of the MPXV.

Fatal Case of Progressive Mpox in a Patient with AIDS-Viral Enteropathy and Malabsorption Demanding the Use of Full Parenteral ARV and Endovenous Cidofovir

We report a fatal case of disseminated mpox infection that progressed over more than three months in an HIV-infected patient with acquired immunodeficiency syndrome (AIDS). Mucocutaneous, pleuropulmonary, central nervous system, and gastrointestinal involvement was documented. This course of disease resembles progressive vaccinia, a formerly reported disease caused by uncontrolled replication of smallpox vaccination orthopoxviruses in immunosuppressed patients. Severe small bowel involvement jeopardized normal oral tecovirimat and antiretroviral therapy absorption. This problem prompted the use of full parenteral antiretrovirals and endovenous cidofovir. Although a remarkable decrease in HIV viral load occurred in six days, mpox infection continued to progress, and the patient died of septic shock. This case offers new clinical insights on the presentation of severe disease in AIDS patients. Moreover, this case alerts for the need for prompt therapy initiation in patients at risk of ominous clinical progression.

Four Human Mpox Cases from Turkey

Human mpox (formerly monkeypox) disease has recently been reported in a number of European countries among individuals with no history of international travel or animal contact, causing global epidemic concerns. We describe the demographic, clinical characteristics, and laboratory data of four male patients with mpox disease, three of whom were human immunodeficiency virus (HIV)-positive, and one who was HIV-negative but had type 1 diabetes mellitus and a recent history of urological surgery. The HIV-negative patient attracted interest because he had no history of suspected sexual contact; however, he used shared bathrooms and towels at work, which could explain the potential transmission route. The remaining three male patients engaged in sexual activity with men recently. All four patients had prodromal symptoms such as short-term fever, myalgia, or fatigue, followed by a vesicular-pustular rash that began in the genital area, and two also had lesions on other parts of their bodies. Mpox is not generally considered in the differential diagnosis intitally because it is rare in Turkey; however, the diagnosis should be considered in patients with pustular umbilicated lesions and a history of risky sexual behavior.

[Monkeypox: Important facts for the ophthalmologist]

The current monkeypox virus (MPXV) outbreak, raging since May 2022, is the largest ever observed on a world-wide scale. Despite previously being endemic in west and central Africa with a mortality rate of up to 10%, it remained a neglected tropical disease. Along with other recent pandemics gaining much attention, this MPXV outbreak has provided an opportunity to improve our understanding of its physiopathology and better define management strategies, particularly in patients with more serious disease. From the ophthalmologist's perspective, eyelid involvement and conjunctivitis or keratoconjunctivitis are frequently observed and may precede systemic signs or even remain the major site of involvement. While the course of MPXV keratoconjunctivitis is most often favorable, severe cases pose a functional threat, in particular for immunocompromised patients. This review provides an overview of MPXV pathophysiology, diagnosis and treatment, as well as considerations for prevention of transmission. During such an epidemic, the ophthalmologist can be the first to diagnose MPXV, treat the ocular involvement, and set up adequate preventative measures in collaboration with infectious disease specialists.

Diagnostic approach to monkeypox outbreak, a case-control study

BACKGROUND

An international outbreak of the monkeypox (MPX) virus is ongoing with a different clinical presentation than previously reported.

OBJECTIVE

A monocentric retrospective study was designed to investigate clinical predictors of confirmed MPX cases among a group of patients referred for MPX screening. Furthermore, the additional value of performing a real-time polymerase chain reaction (RT-PCR) on multiple anatomical sites was analyzed.

METHODS

Between 28/05/2022 and 22/07/2022, the medical records of patients referred for MPX screening were investigated. Patients with positive RT-PCR were defined as cases, while the ones with negative RT-PCR as controls. Multivariable regression analysis was performed to estimate predictors of MPX diagnosis.

RESULTS

Among the 141 included patients, 85 (60%) had at least one positive RT-PCR for MPX. Carrying out RT-PCR only on the swab obtained by skin lesion sampling, 7 patients (7/85: 8%) would have been misdiagnosed. Multivariable regression analysis showed significant differences in the independent variables: "being men who have sex with men (MSM)", "living with HIV", "having multiple sexual partners in the last 3 weeks", and "having skin lesions in the anogenital area" for prediction of MPX diagnosis. These four discriminants were used to create a score to improve diagnosis in patients screened for MPX.

CONCLUSION

MPX diagnosis was associated with being MSM, living with HIV, having multiple sexual partners, and presenting with anogenital skin lesions. In this study, the derived score had good sensitivity and specificity to predict MPX diagnosis. Finally, performing multi-site swabs for MPX RT-PCR might lower false negative rates.

Epidemiologic Situation of HIV and Monkeypox Coinfection: A Systematic Review

The most recent monkeypox (Mpox) outbreak is mostly affecting men who have sex with men (MSM) who participate in high-risk sexual behaviors, which is typically the case among human immunodeficiency virus (HIV) carriers, according to clinical and epidemiological statistics. The objective of this research is to determine the epidemiological situation of HIV and smallpox co-infection. Until 1 October 2022, a thorough evaluation of the literature was conducted utilizing the databases PubMed, Embase, Scopus, and Web of Science. Studies were evaluated based on the criteria for selection. Fifty-three studies met the selection criteria. A total of 6345 confirmed cases of monkeypox were recorded, and 40.32% (n = 2558) of these cases also had HIV co-infection. In addition, 51.36% (n = 3259) of the men (91.44%; n = 5802), whose ages ranged from 18 to 71 years, exhibited MSM-specific sexual behaviors. Co-infection with these two viruses can be especially dangerous because it can exacerbate the symptoms of both diseases and make them more difficult to treat. People with HIV are more vulnerable to certain infections, including monkeypox, because their immune systems are weakened. Therefore, it is important that they take measures to prevent infection, such as avoiding contact with infected animals, risky behaviors, and maintaining good hygiene.

Atypical monkeypox presentation in a previously vaccinated MSM HIV-positive adult

The outbreak of monkeypox virus (MPXV) in non-endemic countries is an international public health emergency, and the diversity in manifestations poses challenges for early diagnosis and isolation. We describe an atypical case of monkeypox (MPX) in a 46-year-old homosexual male living with HIV. He reported 1-day duration fever, a lesion on his chin that, over a period of 18 days, had gradually enlarged and ulcerated. Biopsy examination performed at an external centre revealed pyoderma gangrenosum, unconfirmed at a subsequent biopsy. When he reported to our hospital outpatients' clinic the chin lesion had a diameter of 5 × 5 cm, necrotic margins and ulcerated base and signs of superinfection. He was admitted for further investigations. Three swabs collected from pharynx, skin and chin lesion resulted positive for MPXV. He had a favourable clinical course and was discharged soon after. Pending the achievement of optimal vaccination coverage in at-risk groups, early identification and isolation of infectious patients represent the cornerstones of the containment strategy. Atypical cases of MPX manifestations are not uncommon, particularly in patients with HIV infection. A high level of suspicion should be maintained to identify infectious cases at an early stage and avoid further spread of the infection.

Non-painful, Non-itchy Monkeypox Virus Rash: A Case Report

Monkeypox virus (MPVX) is a double-stranded deoxyribonucleic acid (DNA) virus from the genus Orthopoxvirus, family Poxviridae. Many cases of MPVX infection are currently seen worldwide. Although the majority of cases reported are not severe, basic precautionary measures are key to preventing this infection from turning into a catastrophic pandemic. We report a case of a 54-year-old male with no high-risk behavior who developed a sudden uncharacteristic monkeypox virus rash while on a flight from Nigeria.

Comprehensive Literature Review of Monkeypox

The current outbreak of monkeypox (MPX) infection has emerged as a global matter of concern in the last few months. MPX is a zoonosis caused by the MPX virus (MPXV), which is one of the Orthopoxvirus species. Thus, it is similar to smallpox caused by the variola virus, and smallpox vaccines and drugs have been shown to be protective against MPX. Although MPX is not a new disease and is rarely fatal, the current multi-country MPX outbreak is unusual because it is occurring in countries that are not endemic for MPXV. In this work, we reviewed the extensive literature available on MPXV to summarize the available data on the major biological, clinical and epidemiological aspects of the virus and the important scientific findings. This review may be helpful in raising awareness of MPXV transmission, symptoms and signs, prevention and protective measures. It may also be of interest as a basis for performance of studies to further understand MPXV, with the goal of combating the current outbreak and boosting healthcare services and hygiene practices.Trial registration: ClinicalTrials.gov identifier: NCT02977715..Trial registration: ClinicalTrials.gov identifier: NCT03745131..Trial registration: ClinicalTrials.gov identifier: NCT00728689..Trial registration: ClinicalTrials.gov identifier: NCT02080767..

Monkeypox and HIV in the Canary Islands: A Different Pattern in a Mobile Population

BACKGROUND

The clinical and epidemiological data of the recent outbreak of monkeypox (MPX) differ from previous reports. One difference is the epidemiological profile; the disease mainly affects a subgroup of MSM (men who have sex with men) with high-risk sexual behaviors, frequently persons living with human immunodeficiency virus (PLHIV).

METHODS

In this observational analysis, all patients with PCR (polymerase chain reaction)-confirmed MPX attending an Infectious Diseases and Tropical Medicine Unit in Gran Canaria (Spain) between May and July 2022 were considered.

RESULTS

In total, 42 men were included; 88% were identified as MSM, with a median age of 40 years. Only 43% were born in Spain. All the patients had systemic symptoms and skin lesions. The distribution of lesions was more frequent in the genital/anal region, and the involvement of hands and feet was less common. Fever and lymphadenopathies were less frequent than in other series. Other unusual manifestations were proctitis, pharyngitis and penile-scrotal edema. Half of the patients had other associated infections (mainly STIs, sexually transmitted infections), and 60% of the monkeypox patients had PLHIV (People Living with HIV). When comparing the clinical characteristics between HIV-positive and -negative patients, we found three main differences: (i) a higher frequency of perioral lesions, (ii) a higher frequency of pharyngitis and (iii) a higher number of sexually transmitted infections in HIV-positive patients.

CONCLUSIONS

The clinical findings in this outbreak of MPX had great variability in presentation. Several clinical differences were found in PLHIV-coinfected patients.

Monkeypox, a Literature Review: What Is New and Where Does This concerning Virus Come From?

Among the Poxviridae family, orthopoxvirus is the most notorious genus. Several DNA viruses belonging to this group are known to produce human disease from the life-threatening variola virus (VARV) (the causative agent of smallpox), monkeypox virus (MPXV), cowpox virus (CPXV), and vaccinia virus (VACV). These orthopoxviruses still remain a public health concern as VACV or CPXV still cause emerging endemic threads, especially in developing countries. MPXV is able to cause sporadic human outbreaks of a smallpox-like zoonotic disease and, in May 2022, hundreds of cases related to MPXV have been reported from more than 30 countries around the globe. At the end of July, monkeypox (MPX) outbreak was even declared a global health emergency by the World Health Organization (WHO). Many aspects remain unclear regarding this outbreak and a deep understanding of orthopoxvirus might have crucial and evident implications. During the era in which people under 45 years old are not protected against VACV, the potential use of orthopoxviruses as a biological weapon raises global concern considering the rapid spreading of the current MPX outbreak in vulnerable populations. Hence, we review the most recent evidence about phylogenesis, pathogenesis, prevention, and treatment for this concerning disease.

Clinical features, hospitalisation and deaths associated with monkeypox: a systematic review and meta-analysis

INTRODUCTION

A multicountry monkeypox disease (MPX) outbreak began in May 2022 in Europe, leading to the assessment as a potential Public Health Emergency of International Concern (PHEIC) on June 23, 2022. Some observational studies have partially characterised clinical features, hospitalisations, and deaths. However, no systematic reviews of this MPX outbreak have been published.

METHODS

We performed a systematic review with meta-analysis, using five databases to assess clinical features, hospitalisations, complications and deaths of MPX confirmed or probable cases. Observational studies, case reports and case series, were included. We performed a random-effects model meta-analysis to calculate the pooled prevalence and 95% confidence interval (95% CI). In addition, we carried out a subgroup analysis according to the continents and a sensitivity analysis excluding studies classified as having a high risk of bias.

RESULTS

A total of 19 articles were included, using only 12 articles in the quantitative synthesis (meta-analysis). For 1958 patients, rash (93%, 95% CI 80-100%), fever (72%, 95% CI 30-99%), pruritus (65%, 95% CI 47-81%), and lymphadenopathy (62%, 47-76%), were the most prevalent manifestations. Among the patients, 35% (95% CI 14-59%) were hospitalised. Some 4% (95% CI 1-9%) of hospitalised patients had fatal outcomes (case fatality rate, CFR).

CONCLUSION

MPX is spreading rapidly, with a third of hospitalised patients, but less than 5% with fatal outcomes. As this zoonotic virus spreads globally, countries must urgently prepare human resources, infrastructure and facilities to treat patients according to the emerging guidelines and the most reliable clinical information.