Severe disseminated clinical presentation of monkeypox virus infection in an immunosuppressed patient: first death report in Brazil

Mpox Virus and its ocular surface manifestations

The Mpox virus (MPXV) is the causative agent of human Mpox disease - a debilitating rash illness similar to smallpox. Although Clade I MPXV has remained endemic to West and Central Africa, Clade II MPXV has been responsible for many outbreaks worldwide. The most recent outbreak in 2022 resulted from the rapid spread of a new clade of MPXV, classified into Clade IIb - a distinct lineage from the previously circulating viral strains. The rapid spread and increased severity of Mpox disease by the Clade IIb strain have raised the serious public health imperative of better understanding the host and viral determinants during MPXV infection. In addition to typical skin rashes, including in the periorbital area, MPXV causes moderate to severe ophthalmic manifestations - most commonly, ocular surface complications (e.g., keratitis, conjunctivitis, blepharitis). While ocular manifestations of Clade I Mpox within the Congo basin have been well-reported, global incidence trends of ocular Mpox cases by Clade IIb are still emerging. Given the demonstrated ability of all MPXV strains to auto-inoculate ocular tissue, alongside the enhanced transmissibility of the Clade IIb virus, there is an urgent need to elucidate the mechanisms by which MPXV causes ocular anomalies. In this review, we discuss the viral and genomic structures of MPXV, the epidemiology, and pathology of systemic and ocular Mpox, as well as potential prophylactic and therapeutic interventions.

Exploring self-care practices and health beliefs among men in the context of emerging infectious diseases: Lessons from the Mpox pandemic in Brazil

Our goal was to explore self-care practices among men who have sex with men in the context of Mpox in Brazil. This study used qualitative research methods, including interviews and thematic analysis, to collect and analyze data from male participants across the Brazilian territory. The narratives unveil men's perspectives on self-care, risk reduction, and health beliefs during the Mpox pandemic. Our findings highlight a multifaceted approach to self-care among men, encompassing hygiene, physical contact management, mask usage, skin lesion vigilance, and adherence to official guidelines. Men's attitudes toward sexual behaviors emphasize the importance of reducing sexual partners, practicing safe sex, and combating misinformation through accurate information dissemination. The development of these behaviors and self-care practices can be facilitated by nurses guided by Dorothea Orem's Self-Care Theory, supported by patient-centered care, with strategies to address and confront the stigma associated with the disease and provide emotional support. Thus, the study underscores the pivotal role of self-care in mitigating infection risks, especially in the context of emerging infectious diseases. It acknowledges the impact of socio-cultural factors and healthcare policies on men's preventive measures. However, it also recognizes limitations, such as potential bias due to stigma concerns and a nonrepresentative sample. Ultimately, the research advocates for tailored education, promotion of gender equity, and healthcare empowerment to effectively manage health risks in such contexts.

The impact of immunosuppression on the mortality and hospitalization of Monkeypox: a systematic review and meta-analysis of the 2022 outbreak

BACKGROUND

Limited data is available regarding the severity and mortality of Mpox in individuals with immunocompromised conditions. Therefore, we performed this meta-analysis to understand the impact of HIV- or non-HIV-associated immunosuppression on the severity of Mpox requiring hospitalization and mortality.

METHODS

A thorough literature search was performed from 2022 up to January 2024. The results were presented as odds ratios (ORs). We only included patients who required hospitalization for severity rather than isolation.

RESULTS

A total of 34 studies were included in this analysis. Our analysis did not find a significant difference in the hospitalization risk between HIV-positive individuals and those who were HIV-negative (OR = 1.03; P = 0.85; 7 studies; CD4 count of fewer than 200 cells/µL was less than 0.5% across all studies). Patients with a CD4 count lower than 200 cells/µL or an unsuppressed RNA viral load (> 200 copies/ml) had a significantly higher hospitalization risk (OR = 5.3, P < 0.001) and (OR = 3, P < 0.001), respectively. Most of the reported deaths were reported in patients with HIV with CD4 counts below 200 cells/µL, with some fatal cases occurring in non-HIV immunosuppressed patients, particularly organ transplant recipients. Based on the autopsy findings, Mpox was confirmed in multiple organs, particularly the digestive tract, lung, and testes. Furthermore, some studies documented cases of death that were suspected to be related to hemophagocytic lymphohistiocytosis (HLH) and immune reconstitution inflammatory syndrome (IRIS). Most of the death reports showed concomitant non-Mpox infections at the time of hospitalization and death CONCLUSIONS: Our finding shows that Mpox acts as an opportunistic pathogen in immunocompromised individuals. These individuals should be prioritized for early care and closely monitored for signs of deteriorating clinical conditions. Clinical manifestations and autopsy findings strongly suggest Mpox dissemination to multiple organs, particularly the digestive tract, and lungs. However, the presence of concomitant non-Mpox infections complicates the assessment of the attribution of Mpox to death. Caution should be exercised when interpreting data suggesting poorer outcomes in individuals with non-HIV immunosuppression, as current evidence is scarce and further research is needed.

Widespread necrotic vesicles with genital involvement

We present a clinicopathological challenge consisting of disseminated herpes zoster that simulated mpox. We emphasize the utility of diagnosis with the Tzanck test and skin biopsy, as well as the importance of understanding the clinical picture, owing to its potential severity

Mpox as AIDS-defining event with a severe and protracted course: clinical, immunological, and virological implications

A 59-year-old treatment-naive patient with advanced HIV infection presented with a severe and protracted course of mpox (formerly known as monkeypox) that did not respond to the current mpox treatment options. The patient worsened clinically, and developed new mucocutaneous lesions and necrotic evolution of pre-existing ones, along with multiple bilateral lung nodules and the appearance of a tracheal necrotic lesion. Although severe forms of mpox have been observed in people with severe immune system deficiency, including those with advanced HIV presentation, the immunological mechanisms underlying this observation have not yet been fully explained. To our knowledge, this is the first account of a necrotising mpox in a person living with HIV, with viral shedding for more than 11 months and a comprehensive immunological description. Moreover, we documented the virus' persistence by detecting mpox virus DNA from multiple sites and quantified anti-monkeypox virus IgA, IgM, IgG, and neutralising antibodies in serum samples. The severe HIV-driven immune depression and the presence of other co-infections might skew and impair immune responses, thus contributing to the persistence of monkeypox virus infection. Further investigations of immune responses to monkeypox virus infection in people with severe immunosuppression are required to improve management and prevention.

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.

Clinical review of human mpox

BACKGROUND

Historically, human mpox was predominantly a zoonotic disease occurring more frequently in rural children in Africa and characterized by a largely self-limiting febrile centrifugal monomorphic rash illness. However, the 2022 mpox global outbreak has shown that the disease is changing in many ways, including sustained human-to-human transmission via sexual contact, novel clinical presentations, and adverse associations between mpox and advanced HIV.

OBJECTIVES

The aim of this paper is to review the traditional and emerging clinical aspects of human mpox and provide updated information on the clinical course and outcome of the disease.

SOURCES

We searched electronic databases including PubMed and Google Scholar and identified relevant published literature on mpox.

CONTENT

The clinical presentation of human mpox is influenced by the route of infectious exposure, the strain and dose of the infecting virus, and the host immune system. Exposure to the virus can result in sub-clinical or clinical diseases of variable severity. Infections caused by clade I viral strains are more severe than class IIa and IIb strains, which are associated with a milder febrile rash illness, and with anogenital skin lesions in clade IIb infections. Most cases of mpox recover entirely within 2-4 weeks after onset of illness and a few develop skin-related sequelae. Overall, people with advanced HIV infection, children <5 years of age, and pregnant women may present with more severe disease and higher case fatalities.

IMPLICATIONS

The continued endemicity of the classical mpox in Africa, the emergence of a new clinical form of the disease during the 2022 global outbreak, and the adverse associations between advanced HIV and mpox have implications for the surveillance, clinical diagnosis, and management of human mpox.

Clinical, molecular, and histological characteristics of severely necrotic and fatal mpox in HIV-infected patients

BACKGROUND

This case series of 5 patients with severely necrotic mpox highlights the predominantly necrotic nature of lesions seen in cases of severe mpox as shown by skin and lung biopsy, as well as the extensive dissemination of the infection, as shown by polymerase chain reaction (PCR) assessment in different body sites.

CASE PRESENTATIONS

Patients were male, the median age was 37, all lived with HIV (2 previously undiagnosed), the median CD4+ cell count was 106 cells/mm3, and 2/5 were not receiving antiretroviral treatment. The most common complication was soft tissue infection. Skin and lung biopsies showed extensive areas of necrosis. Mpox PCR was positive in various sites, including skin, urine, serum, and cerebrospinal fluid. The initiation of antiretroviral treatment, worsened the disease, like that seen in immune reconstitution syndrome. Three patients died due to multiple organ failure, presumably associated with mpox since coinfections and opportunistic pathogens were ruled out.

CONCLUSIONS

Severely necrotic manifestations of mpox in people living with advanced and untreated HIV are related to adverse outcomes.

Knowledge, Attitudes, and Willingness of Healthcare Workers in Iraq's Kurdistan Region to Vaccinate against Human Monkeypox: A Nationwide Cross-Sectional Study

Although human monkeypox infections had not been recorded in the Kurdistan region of Iraq as of August 2023, the rapid growth of cases worldwide and the detection of monkeypox in neighboring Middle Eastern nations call for careful planning and timely response measures. Educating and empowering frontline healthcare workers (HCWs) so that they can act to curb the spread of monkeypox infections are core elements of primary prevention and protecting public health. Therefore, this study aimed to assess HCWs' knowledge and attitudes about monkeypox and their willingness to vaccinate against monkeypox. By employing a convenience sampling method, an online survey was disseminated via Google Forms between 1 November 2022 and 15 January 2023. The researchers utilized regression analyses to ascertain the factors associated with the three parameters: knowledge, attitude, and the willingness to vaccinate. A total of 637 HCWs were included in the analysis (ages ranged between 21 and 51 years). The mean overall scores were 8.18 of a max score of 16 (SD 3.37), 3.4 of 5 (SD 1.37), and 2.41 of 5 (SD 1.25) for knowledge, attitude, and willingness to vaccinate, respectively. A multivariate logistic regression analysis demonstrated that HCWs who had heard about monkeypox before 2022 rather than later had a higher level of knowledge (AOR: 4.85; 95% CI: 2.81-8.36; p < 0.001). In addition, those who had newly joined the workforce or had less than 1 year experience in practice had more positive attitudes about curbing monkeypox (AOR: 0.35; 95% CI: 0.20-0.59; p < 0.01) than those who practiced for longer. No significant predictors of willingness to vaccinate against monkeypox were identified. The research revealed that HCWs exhibited a relatively low level of monkeypox knowledge. They also had poor attitudes towards monkeypox vaccination and were therefore reluctant to receive the vaccines. Imparting knowledge about the infectious disease can cultivate better awareness and attitudes among HCWs as to their roles in mitigating the spread of an epidemic in the foreseeable future.

Severe mpox in patients with advanced AIDS: long-term disease and fatal outcome

Herein, we report two cases of severe mpox in patients with advanced acquired immunodeficiency syndrome from Brazil who developed atypical lesions and prolonged illness, one of whom had a fatal outcome. Both patients experienced serious complications involving the perianal and genital regions and prolonged disease with persistent viremia.

Absence of association between persistent skin lesion and virological replication in severe disseminated monkeypox infection in solid organ transplant recipient

The Monkeypox (mpox) virus outbreak has been controlled worldwide. We report the case of a combined pancreas-kidney transplant recipient who presented a severe and prolonged cutaneous infection with onset of 3 successive rashes while receiving tecovirimat therapy. During follow-up, skin lesions, blood and throat samples were collected. Viral culture and mpox PCR were performed. No positive viral culture was obtained from blood and throat. The lowest mpox CT-values were obtained early after onset of skin lesions and were more likely to be associated with positive viral cultures. Furthermore, we observed persistent skin lesions up to 3 months. On these persistent lesions, mpox PCR positives were obtained but were not associated with positive viral culture after 23 days. In this immunocompromised host, who was receiving tecovirimat, in accordance with existing recommendations a 21-day isolation period appeared to be adapted. That said, isolation should not be systematically extended if complete healing of skin lesions has not been achieved.

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.

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.

Epidemiologic and Clinical Features of Mpox-Associated Deaths - United States, May 10, 2022-March 7, 2023

As of March 7, 2023, a total of 30,235 confirmed and probable monkeypox (mpox) cases were reported in the United States,^† predominantly among cisgender men^§ who reported recent sexual contact with another man (1). Although most mpox cases during the current outbreak have been self-limited, cases of severe illness and death have been reported (2-4). During May 10, 2022-March 7, 2023, 38 deaths among persons with probable or confirmed mpox^¶ (1.3 per 1,000 mpox cases) were reported to CDC and classified as mpox-associated (i.e., mpox was listed as a contributing or causal factor). Among the 38 mpox-associated deaths, 94.7% occurred in cisgender men (median age = 34 years); 86.8% occurred in non-Hispanic Black or African American (Black) persons. The median interval from symptom onset to death was 68 days (IQR = 50-86 days). Among 33 decedents with available information, 93.9% were immunocompromised because of HIV. Public health actions to prevent mpox deaths include integrated testing, diagnosis, and early treatment for mpox and HIV, and ensuring equitable access to both mpox and HIV prevention and treatment, such as antiretroviral therapy (ART) (5).

Monkeypox (mpox) in immunosuppressed patients

The World Health Organization (WHO) proclaimed a public health emergency in July 2022 due to the emergence of Mpox (formerly monkeypox) while the globe was still dealing with the COVID-19 epidemic. The characteristics of mpox in immunocompetent individuals are well-characterized, despite difficulties in diagnostics, immunization, and access to treatment that persist in low-income countries. Patients with weakened immune systems are more likely to spread an illness and die from it than healthy people because they cannot mount a protective immune response against it, such as a neutralizing IgG and poxvirus-specific Th1 response. A health warning on severe mpox in people who are immunocompromised due to Human Immunodeficiency virus (HIV) and other illnesses was released by the U.S. Centers for Disease Control and Prevention (CDC) on September 29, 2022. The advice does not specifically include primary immunodeficiency, but it does define other immunocompromising disorders as “having autoimmune disease with immunodeficiency as a clinical component”. Both those with healthy immune systems and those with weakened immune systems, such as those who are immunosuppressed, older people, children, etc., have encountered serious health issues, but the latter group is more likely to do so. According to the advisory, “of the people with severe mpox manifestations for whom CDC has been consulted, the majority have had HIV with CD4 counts 200 cells/ml, indicating substantial immunosuppression”. However, new cases are still expected to be discovered, especially in low-income countries with limited access to diagnosis, treatment, and prevention, and where a large percentage of the mpox-infected population also has advanced HIV infection. Thus, further research is always needed to determine the best way to treat mpox in immunocompromised people. In this context, we discussed /reviewed the mpox clinical presentation, available treatment options and current preventive guidelines in immunocompromised patients.

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.

Monkeypox clinical disease: Literature review and a tool proposal for the monitoring of cases and contacts

The human monkeypox disease has mainly been described in Western and Central Africa. Since May 2022, the monkeypox virus has been spreading worldwide in a new epidemiological pattern, where cases result from person-to-person transmission, and develop clinically milder or less typical illness than during previous outbreaks in endemic areas. The newly-emerging monkeypox disease needs to be described over the long term, to improve cases definitions, to implement prompt control measures against epidemics, and to provide supportive care. Hence, we first conducted a review of historical and recent outbreaks to define the full clinical spectrum of the monkeypox disease and its course known so far. Then, we built a self-administrated questionnaire collecting daily symptoms of the monkeypox infection to follow cases and their contacts, even remotely. This tool will assist in the management of cases, the surveillance of contacts, and the conduct of clinical studies.

Monkeypox (mpox) in immunosuppressed patients

The World Health Assembly declared that smallpox had been completely eradicated from the human population in 1980. Monkeypox, a zoonosis native to damp forested regions in West and Central Africa, is the illness that is most comparable to smallpox clinically and immunologically. Both illnesses could be prevented by the smallpox vaccine. Although the monkeypox virus is a less effective human disease than the smallpox virus, it could now spread among human populations if smallpox had not been eradicated and population-wide immunity had not been developed. A health warning on severe monkeypox in people who are immunocompromised due to Human Immunodeficiency virus (HIV) and other illnesses was released by the U.S. Centers for Disease Control and Prevention (CDC) on September 29, 2022. The advise does not specifically include primary immunodeficiency, but it does define other immunocompromising disorders as “having autoimmune disease with immunodeficiency as a clinical component”. The documented severe signs of monkeypox include widespread rashes with secondary fungal or bacterial skin infections or tissue death (necrosis), intestine obstruction, and difficulties with the heart, lungs, urinary system, and nervous system. Both those with healthy immune systems and those with weakened immune systems, such as those who are immunosuppressed, older people, children, etc., have encountered serious health issues, but the latter group is more likely to do so. According to the advisory, “of the people with severe monkeypox manifestations for whom CDC has been consulted, the majority have had HIV with CD4 counts 200 cells/ml, indicating substantial immunosuppression”. The current article goes into great detail about monkeypox disease occurring in immunocompromised patients and preventive guidelines.

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.

Factors associated with geographic variations in the 2022 monkeypox outbreak; A systematic review

Background

The review aimed at examining patient factors that were associated with the worldwide geographic variation in number of monkeypox cases during the 2022 outbreak.

Methods

A systematic search was conducted using Scopus, Google Scholar, and PubMed/MEDLINE, to identify studies published in the year 2022 until 30 September on the 2022 monkeypox outbreak. Studies that described demographics and patient characteristics of the affected populations were eligible. Only countries/regions with the highest and lowest globally reported numbers were included.

Results

A total of 24 eligible studies reported data from the most affected countries in Europe [Spain and UK]; Americas [USA and Brazil]; and the least affected region [South East Asia]. There were no eligible studies reporting data from the Eastern Mediterranean which was allegedly the least affected region. Cases from Europe and the Americas were mostly men having sex with men [MSM], in fourth and fifth decades of life, with a substantial proportion of HIV and sexually transmitted diseases. Sporadic cases among women [sexual, household] and children [household] were identified. Sexual orientation and/or mode of transmission were not clearly stated in most studies from South East Asia.

Conclusions

The 2022 monkeypox outbreak was most obvious in the western part of the globe due mainly to sexual activities among MSM. Low numbers in the east may indicate the influence of the conservative social behaviors. Co-morbidities in the form of HIV and sexually transmitted diseases were identified. Detection of the disease among women and children highlights the importance of adopting appropriate preventive public health measures.

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.

Ambulatory and hospitalized patients with suspected and confirmed mpox: an observational cohort study from Brazil

Background

By October 30, 2022, 76,871 cases of mpox were reported worldwide, with 20,614 cases in Latin America. This study reports characteristics of a case series of suspected and confirmed mpox cases at a referral infectious diseases center in Rio de Janeiro, Brazil.

Methods

This was a single-center, prospective, observational cohort study that enrolled all patients with suspected mpox between June 12 and August 19, 2022. Mpox was confirmed by a PCR test. We compared characteristics of confirmed and non-confirmed cases, and among confirmed cases according to HIV status using distribution tests. Kernel estimation was used for exploratory spatial analysis.

Findings

Of 342 individuals with suspected mpox, 208 (60.8%) were confirmed cases. Compared to non-confirmed cases, confirmed cases were more frequent among individuals aged 30-39 years, cisgender men (96.2% vs. 66.4%; p < 0.0001), reporting recent sexual intercourse (95.0% vs. 69.4%; p < 0.0001) and using PrEP (31.6% vs. 10.1%; p < 0.0001). HIV (53.2% vs. 20.2%; p < 0.0001), HCV (9.8% vs. 1.1%; p = 0.0046), syphilis (21.2% vs. 16.3%; p = 0.43) and other STIs (33.0% vs. 21.6%; p = 0.042) were more frequent among confirmed mpox cases. Confirmed cases presented more genital (77.3% vs. 39.8%; p < 0.0001) and anal lesions (33.1% vs. 11.5%; p < 0.0001), proctitis (37.1% vs. 13.3%; p < 0.0001) and systemic signs and symptoms (83.2% vs. 64.5%; p = 0.0003) than non-confirmed cases. Compared to confirmed mpox HIV-negative, HIV-positive individuals were older, had more HCV coinfection (15.2% vs. 3.7%; p = 0.011), anal lesions (45.7% vs. 20.5%; p < 0.001) and clinical features of proctitis (45.2% vs. 29.3%; p = 0.058).

Interpretation

Mpox transmission in Rio de Janeiro, Brazil, rapidly evolved into a local epidemic, with sexual contact playing a crucial role in its dynamics and high rates of coinfections with other STI. Preventive measures must address stigma and social vulnerabilities.

Funding

Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz).

Epidemiological and clinical characteristics of monkeypox cases in Brazil in 2022: a cross-sectional study

OBJECTIVE

to describe epidemiological and clinical characteristics of monkeypox (MPX) in Brazil, from the identification of the first case, on June 7, 2022, to Epidemiological Week (EW) 39, ending on October 1, 2022.

METHODS

this was a descriptive study of cases notified to the Ministry of Health; trends were analyzed based on the number of confirmed and probable cases per EW; the cases were also described according to demographic and clinical variables.

RESULTS

out of 31,513 notifications, 23.8% were confirmed; 91.8% were male; 70.6% were cis men; and median age was 32 years. Fever (58.0%), adenomegaly (42.4%), headache (39.9%) and rash (37.0%) were the most frequent symptoms; 27.5% reported being immunosuppressed, 34.6% were living with HIV and 10.5% had a sexually transmitted infection; three deaths were recorded.

CONCLUSION

the MPX case profile was similar to that of other countries; surveillance actions must be strengthened to control the outbreak.