Myocarditis Attributable to Monkeypox Virus Infection in 2 Patients, United States, 2022

Monkeypox virus protein H3L induces injuries in human and mouse

Monkeypox virus (MPV) is known to inflict injuries and, in some cases, lead to fatalities in humans. However, the underlying mechanisms responsible for its pathogenicity remain poorly understood. We investigated functions of MPV core proteins, H3L, A35R, A29L, and I1L, and discovered that H3L induced transcriptional perturbations and injuries. We substantiated that H3L upregulated IL1A expression. IL1A, in consequence, caused cellular injuries, and this detrimental effect was mitigated when countered with IL1A blockage. We also observed that H3L significantly perturbed the transcriptions of genes in cardiac system. Mechanistically, H3L occupied the promoters of genes governing cellular injury, leading to alterations in the binding patterns of H3K27me3 and H3K4me3 histone marks, ultimately resulting in expression perturbations. In vivo and in vitro models confirmed that H3L induced transcriptional disturbances and cardiac dysfunction, which were ameliorated when IL1A was blocked or repressed. Our study provides valuable insights into comprehensive understanding of MPV pathogenicity, highlights the significant roles of H3L in inducing injuries, and potentially paves the way for the development of therapeutic strategies targeting IL1A.

Human monkeypox virus: Epidemiologic review and research progress in diagnosis and treatment

Monkeypox virus (MPXV) is responsible for causing a zoonotic disease called monkeypox (mpox), which sporadically infects humans in West and Central Africa. It first infected humans in 1970 and, along with the variola virus, belongs to the genus Orthopoxvirus in the poxvirus family. Since the World Health Organization declared the MPXV outbreak a "Public Health Emergency of International Concern" on July 23, 2022, the number of infected patients has increased dramatically. To control this epidemic and address this previously neglected disease, MPXV needs to be better understood and reevaluated. In this review, we cover recent research on MPXV, including its genomic and pathogenic characteristics, transmission, mutations and mechanisms, clinical characteristics, epidemiology, laboratory diagnosis, and treatment measures, as well as prevention of MPXV infection in light of the 2022 and 2023 global outbreaks. The 2022 MPXV outbreak has been primarily associated with close intimate contact, including sexual activity, with most cases diagnosed among men who have sex with men. The incubation period of MPXV infection usually lasts from 6 to 13 days, and symptoms include fever, muscle pains, headache, swollen lymph nodes, and a characteristic painful rash, including several stages, such as macules, papules, blisters, pustules, scabs, and scab shedding involving the genitals and anus. Polymerase chain reaction (PCR) is usually used to detect MPXV in skin lesion material. Treatment includes supportive care, antivirals, and intravenous vaccinia immune globulin. Smallpox vaccines have been designed with four givens emergency approval for use against MPXV infection.

Role of vaccination in patients with human monkeypox virus and its cardiovascular manifestations

Human monkeypox, caused by the monkeypox virus (MPXV), is an emerging infectious disease with the potential for human-to-human transmission and diverse clinical presentations. While generally considered milder than smallpox, it can lead to severe cardiovascular complications. The virus primarily spreads through contact with infected animals or through human-to-human transmission. Cardiovascular involvement in human monkeypox is rare but has been associated with myocarditis, pericarditis, arrhythmias, and even fulminant myocardial infarction. Vaccination plays a crucial role in preventing and controlling monkeypox, but the eradication of smallpox has left global populations vulnerable. This review explores the cardiovascular manifestations of human monkeypox, the role of vaccination in disease prevention, and the importance of continued research and development of effective vaccines to protect against this emerging infectious threat. The global impact of monkeypox outbreaks, particularly on vulnerable populations, further highlights the importance of understanding and addressing this disease.

Integrated bioinformatics approaches to investigate alterations in transcriptomic profiles of monkeypox infected human cell line model

BACKGROUND

The recent re-emergence of the monkeypox (mpox) epidemic in nonendemic regions has raised concerns regarding a potential global outbreak. The mpox virus (MPV) is a smallpox-like virus belonging to the genus Orthopoxvirus (family: Poxviridae). Although studies suggest that MPV infection suppresses the Toll-like receptor-3- and tumor necrosis factor-α-related signaling pathways, whether MPV regulates other immune-related pathways remains unclear.

METHODS

In this study, two distinct temporal patterns were used for establishing an MPV-infected human immortal epithelial cancer cell line (HeLa). These two durations 2 and 12 h of incubation were selected to identify the coregulated genes and pathways affected by MPV infection.

RESULTS

The use of the Gene Ontology framework, Kyoto Encyclopedia of Genes and Genome database, and MetaCore software yielded valuable insights. Specifically, various pathways were found to be enriched in HeLa cells infected with MPV for 2 and 12 h. These pathways included Notch, CD40, CD95, hypoxia-inducible factor-1-α, interleukin (IL)- 1, IL-6, phosphoinositide 3-kinase, nuclear factor-κB, mitogen-activated protein kinase, and oxidative stress-induced signalling pathways. Clusters and pathways of metabolism and viral replication cycles were significantly associated with the 2-hour infection group. This association was identified based on the regulation of genes such as HSPG2, RHPN2, MYL1, ASPHD2, CA9, VIPR1, SNX12, MGC2752, SLC25A1, PEX19, and AREG. Furthermore, clusters and pathways related to immunity and cell movement were found to be associated with the 12-hour infection group. This association was identified based on the regulation of genes such as C1orf21, C19orf48, HRK, IL8, GULP1, SCAND2, ATP5C1, FEZ1, SGSH, TACC2, CYP4X1, MMP1, CPB1, P2RY13, WDR27, PRPF4, and ENDOD1.

CONCLUSIONS

This study can improve our understanding of the mechanisms underlying the pathophysiology and post-infection sequelae of mpox. Our findings provide valuable insights into the various modes of MPV infection.

The knowns and unknowns of cardiac autoimmunity in viral myocarditis

Myocarditis can result from various infectious and non-infectious causes that can lead to dilated cardiomyopathy (DCM) and heart failure. Among the infectious causes, viruses are commonly suspected. But the challenge is our inability to demonstrate infectious viral particles during clinical presentations, partly because by that point, the viruses would have damaged the tissues and be cleared by the immune system. Therefore, viral signatures such as viral nucleic acids and virus-reactive antibodies may be the only readouts pointing to viruses as potential primary triggers of DCM. Thus, it becomes hard to explain persistent inflammatory infiltrates that might occur in individuals affected with chronic myocarditis/DCM manifesting myocardial dysfunctions. In these circumstances, autoimmunity is suspected, and antibodies to various autoantigens have been demonstrated, suggesting that immune therapies to suppress the autoimmune responses may be necessary. From this perspective, we endeavoured to determine whether or not the known viral causes are associated with development of autoimmune responses to cardiac antigens that include both cardiotropic and non-cardiotropic viruses. If so, what their nature and significance are in developing chronic myocarditis resulting from viruses as primary triggers.

Cardiovascular Manifestations of Human Monkeypox Virus: An Updated Review

Cardiovascular manifestations in human monkeypox virus (MPXV) infection has gained increasing recognition as significant complications with both social and clinical implications. Myocarditis, viral pericarditis, heart failure, and arrhythmias can occur, leading to adverse effects on individuals' health and quality of life. Understanding the detailed pathophysiology of these cardiovascular manifestations is essential for improved diagnosis and management. The social implications of these cardiovascular complications are multifaceted, ranging from public health concerns and the impact on individuals' quality of life to psychological distress and social stigma. Clinically, diagnosing, and managing these complications present challenges, requiring a multidisciplinary approach and specialized care. The burden on healthcare resources necessitates preparedness and resource allocation to effectively address these complications. We delve into the pathophysiological mechanisms involved, including viral-induced cardiac damage, immune response, and inflammatory processes. Additionally, we explore the types of cardiovascular manifestations and their clinical presentations. Addressing cardiovascular manifestations' social and clinical implications in MPXV infection requires a comprehensive approach involving healthcare professionals, public health authorities, and communities. By prioritizing research, enhancing diagnosis and treatment strategies, and promoting preventive measures, we can mitigate the impact of these complications, improve patient care, and protect public health.

Cardiac Involvement in Monkeypox Outbreak

Unusual presentations and uncommon clinical manifestations of Monkeypox (Mpox) in the current outbreak highlight the need to focus on cardiac symptoms of the virus. Owing to limited discussion regarding cardiac involvement in recent cases of Mpox, we conducted a scoping review to determine the range of existing research and provide a descriptive overview of the current literature on these manifestations. This review was conducted using a previously developed six-stage methodological approach and keeping in view the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR). Records retrieved from PubMed, ScienceDirect and Google Scholar, using a two-step search strategy, were subjected to title and abstract screening, followed by full text screening of remaining articles against specified eligibility criteria. Relevant information was extracted and summarized. Our search yielded 707 records. Following title and abstract screening, 23 articles were retrieved for full text screening. Finally, a total of nine articles were included in this review (three case series and six case reports discussing a total of 13 patients). Myocarditis was identified as the most frequently reported cardiac manifestation of Mpox. Novel clinical presentations included pharyngitis, sore throat, proctalgia, and perianal irritation. Most patients reported chest pain as the primary symptom of cardiac system involvement. Elevated troponin was the most commonly reported investigation finding followed by an elevated C- Reactive Protein. There exists a lack of high-quality studies investigating cardiac system involvement in the current outbreak of Mpox. More information is needed regarding risk factors for cardiac complications, disease progression, and cardio tropism and immunological response to improve preventive/therapeutic strategies. We highlight the paucity of relevant data and call for further discussion to improve the understanding of cardiac manifestations of Mpox. This scoping review sheds light on the underexplored cardiac manifestations of Mpox and highlights the need for heightened awareness of cardiac symptoms in the current outbreak.

Can the current monkeypox affect the heart? A systematic review of case series and case report

BACKGROUND

Monkeypox is a zoonotic viral infection first reported in May 2022. Monkeypox cases present with prodromal symptoms, rash, and/or systemic complications. This study systematically reviews the monkeypox cases presented with any cardiac complications.

METHODS

A systematic literature search was done to locate papers that discuss any cardiac complications associated with monkeypox; then, data were analyzed qualitatively.

RESULTS

Nine articles, including the 13 cases that reported cardiac complications of the disease, were included in the review. Five cases previously had sex with men, and two cases had unprotected intercourse, which reveals the importance of the sexual route in disease transmission. All cases have a wide spectrum of cardiac complications, such as acute myocarditis, pericarditis, pericardial effusion, and myopericarditis.

CONCLUSION

This study clarifies the potential for cardiac complications in monkeypox cases and provides avenues for future research to determine the underlying mechanism. Also, we found that the cases with pericarditis were treated with colchicine, and those with myocarditis were treated with supportive care or cardioprotective treatment (Bisoprolol and Ramipril). Furthermore, Tecovirimat is used as an antiviral drug for 14 days.

Myocarditis in a young male affected with monkeypox infection: a case report

Background

Concerns on monkeypox as a disease impacting global public health first emerged in May, 2022, and, since that time, has been identified in more than 50 countries. The condition mainly affects men who have sex with other men. Cardiac disease is a rare complication of monkeypox infection. Here, we describe a case of myocarditis in a young male subsequently diagnosed with monkeypox infection.

Case summary

A 42-year-old male reported engaging in high-risk sexual behaviours with another male 10 days before presenting to the emergency department with chest pain, fever, maculopapular rash, and a necrotic chin lesion. Electrocardiography revealed diffuse concave ST-segment elevation associated with elevated cardiac biomarkers. Transthoracic echocardiography revealed normal biventricular systolic function without wall motion abnormalities. We excluded other sexually transmitted diseases or viral infections. Cardiac magnetic resonance imaging (MRI) findings suggested myopericarditis involving the lateral wall and adjacent pericardium. The results of polymerase chain reaction (PCR) tests of pharyngeal, urethral, and blood samples were positive for monkeypox. The patient was treated with high-dose non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine and he recovered soon.

Discussion

Monkeypox infections are generally self-limited, with most patients experiencing benign clinical outcomes, no hospitalizations, and few complications. This is a rare report of monkeypox complicated with myopericarditis. Management with high-dose NSAIDs and colchicine relieved our patient's symptoms, suggesting a similar clinical outcome as other idiopathic or virus-related myopericarditis.

Monkeypox virus infection and myocarditis: A review of current evidence and possible pathogenesis

The recent spread of the monkeypox virus (MPXV), causing monkeypox (mpox), to non-endemic areas, and the atypical and unusual clinical manifestations observed during its 2022 outbreak has focused international interest on the clinical features of the disease. Mpox is usually a self-limiting disease with mild symptoms with common manifestations, including fever and skin lesions; however, severe manifestations could occur in some vulnerable groups (children and those with impaired immune systems) and may present multisystem complications and fatal outcomes. In most cases, a fever is the first sign of disease, followed by the development of various inflammatory lesions on the skin, such as vesiculopustular rashes and ulcers. Pneumonitis, encephalitis, keratitis, secondary bacterial infections, acute kidney injury, and myocarditis are all possible outcomes of the infection. Myocarditis has been reported to be caused by orthopoxviruses, and it is a serious condition of which its pathophysiology is little understood. Recent reports have indicated myocarditis with cardiac involvement as a possible atypical and unusual consequence of the MPXV infection during present outbreak. This review provides an overview of the clinical manifestations of mpox with a special focus on its effects on the heart, including myocarditis. The evidence of the myocarditis in mpox patients and its possible pathogenesis are discussed.

Interim Clinical Treatment Considerations for Severe Manifestations of Mpox - United States, February 2023

Monkeypox (mpox) is a disease caused by infection with Monkeypox virus (MPXV), an Orthopoxvirus (OPXV) in the same genus as Variola virus, which causes smallpox. During 2022, a global outbreak involving mpox clade IIb was recognized, primarily among gay, bisexual, and other men who have sex with men.* Most affected patients have been immunocompetent and experienced ≤10 rash lesions (1). CDC has recommended supportive care including pain control.^† However, some patients have experienced severe mpox manifestations, including ocular lesions, neurologic complications, myopericarditis, complications associated with mucosal (oral, rectal, genital, and urethral) lesions, and uncontrolled viral spread due to moderate or severe immunocompromise, particularly advanced HIV infection (2). Therapeutic medical countermeasures (MCMs) are Food and Drug Administration (FDA)-regulated drugs and biologics that are predominantly stockpiled by the U.S. government; MCMs developed for smallpox preparedness or shown to be effective against other OPXVs (i.e., tecovirimat, brincidofovir, cidofovir, trifluridine ophthalmic solution, and vaccinia immune globulin intravenous [VIGIV]) have been used to treat severe mpox. During May 2022-January 2023, CDC provided more than 250 U.S. mpox consultations. This report synthesizes data from animal models, MCM use for human cases of related OPXV, unpublished data, input from clinician experts, and experience during consultations (including follow-up) to provide interim clinical treatment considerations. Randomized controlled trials and other carefully controlled research studies are needed to evaluate the effectiveness of MCMs for treating human mpox. Until data gaps are filled, the information presented in this report represents the best available information concerning the effective use of MCMs and should be used to guide decisions about MCM use for mpox patients.

Case Report: Mpox - Not Just a Rash

Mpox (formally monkeypox) is an Orthopoxvirus associated with both zoonotic and person-to-person spread. Human mpox classically presents with rash and systemic symptoms. Although sporadic outbreaks of mpox have occurred worldwide, the 2022 outbreak is the first of pandemic significance. Thousands of geographically dispersed cases were reported beginning in May 2022. The clinical presentations and outcomes of mpox infection have varied greatly based on viral clade. Further guidance is needed for clinicians to diagnose and treat this emerging infection. We present five clinical vignettes of confirmed cases diagnosed in June and July 2022 in northern California to demonstrate the range of mpox disease, including myocarditis, pharyngitis, epididymitis, and proctitis. We note a significant overlap with HIV infection and a high rate of concurrent sexually transmitted infection. Given the heterogenous presentations of mpox disease, clinicians should maintain a high degree of suspicion in patients with oropharyngeal or genital lesions, proctitis, or new rash.

Myocarditis in monkeypox-infected patients: a case series

OBJECTIVES

Monkeypox, a zoonotic orthopoxvirus, has spread to many countries in recent months, involving mostly men who have sex with men with multiple partners. Clinical presentation includes skin lesions, systemic signs, and less frequent skin superinfections or anorectal and ophthalmic involvements. We aim to detail cases of myocarditis attributable to monkeypox, an entity that has been poorly described.

METHODS

This is a descriptive case series reporting three cases of myocarditis that occurred in patients infected with monkeypox in France in 2022.

RESULTS

Patients were adult men with no medical history who had skin lesions with positive polymerase chain reaction for monkeypox virus. A few days after the onset of cutaneous signs, patients developed acute chest pain, elevated cardiac markers, and biological inflammatory syndrome compatible with myocarditis. Two patients presented electrocardiogram abnormalities and decreased ejection fraction associated with kinetic disturbances on transthoracic electrocardiography. The last patient had normal transthoracic electrocardiography and normal electrocardiogram, but cardiac magnetic resonance imaging showed segmental inferolateral acute myocarditis. Patients were hospitalized and received cardioprotective treatment. One received antiviral treatment with tecovirimat. Symptoms and laboratory abnormalities rapidly resolved in all patients.

DISCUSSION

These cases suggest an association between monkeypox infections and cardiac inflammatory complications. The development of chest pain in an infected patient should not be underestimated and should lead to prompt investigations for myocarditis. Monkeypox infection should also be included in the differential diagnosis of myocarditis, particularly in at-risk patients such as men who have sex with men with multiple partners in whom complete examination for skin or mucosal lesions should thus be performed.

Monkeypox-Induced Myocarditis: A Systematic Review

Monkeypox virus has emerged in different parts of the world with varying clinical symptoms and outcomes. To date, only a few studies have reported cardiac manifestations among monkeypox-infected patients. We aim to systematically evaluate the symptoms, imaging findings, management, and outcomes among monkeypox-induced myocarditis patients. We conducted a systematic literature search in PubMed, Embase, and Scopus from inception till 5th January 2023 by using predefined MESH terms and "AND" and "OR." The following search terms were used: "monkeypox virus" AND "myocarditis." A total of 6 studies with 9 monkeypox-induced myocarditis patients were included in this analysis. The mean age of patients was 33.6 years, with all being male patients. The most common symptoms were fever (89%) and chest pain (100%). Electrocardiogram findings showed 44% of patients had ST-elevation, and 22% had sinus tachycardia. The echocardiographic findings show a mean ejection fraction of 52.14%, while 57% of patients had preserved ejection fraction, and 67% had normal wall motion. Cardiac magnetic resonance findings show 40% of patients had late gadolinium enhancement, and 40% had edema. Management of patients was primarily supportive (33%), and 33% of patients were administered Beta blockers and ACE inhibitors. Overall all patients survived with a good prognosis. Our study's findings show that all cases were reported among male patients with the most common symptoms of chest pain. The overall prognosis was good, with no mortality reported. Infected patients complaining of chest pain should not be ignored, and proper investigation of myocarditis must be considered.

Clinical Characteristics of Human Mpox (Monkeypox) in 2022: A Systematic Review and Meta-Analysis

Since May 2022, large numbers of human mpox (previously known as monkeypox) cases have been reported in non-endemic regions. We conducted a systematic review and meta-analysis to elucidate clinical characteristics of the current mpox outbreak. Our systematic review and meta-analysis were undertaken according to PRISMA and MOOSE guidelines. We searched PubMed, EMBASE, and Web of Science for publications between 1 January and 11 November 2022. Random-effects models were used to pool results. Heterogeneity was assessed using I2. This study is registered with PROSPERO, CRD42022355590. Skin lesions (95.2%, 95% CI [93.3-96.9%]), fever (58.4%, [54.9-61.8%]) and lymphadenopathy (53.0%, [48.7-57.3%]) were the most common symptoms. The most common dermatological manifestations were anogenital lesions (65.7%, [57.8-73.0%]), and the most common lymphadenopathy was inguinal (46.8%, [40.6-53.0%]). There were no differences in symptoms including malaise, fever, headache, and genital, anal, and oropharyngeal lesions according to HIV infection status. Median age of patients varied from 15 to 57.5 years (median, 35 years). The median proportion of men who had sex with men (MSM) was 100.0% (20.6-100.0%). The median proportion of patients who reported recent sexual exposure was 99.2% (14.3-100.0%). The median proportion of PLHIV was 42.2% (0.0-100.0%). Skin lesions, fever, inguinal lymphadenopathy, and anogenital lesions were the most common symptoms of mpox reported in the current outbreak. Existing guidelines should be updated to reflect these clinical manifestations and groups at highest risk of infection, MSM in particular.

Case report: From monkeypox pharyngitis to myopericarditis and atypical skin lesions

Background

A global outbreak of the human monkeypox virus (HMPXV), first identified in May 2022, was declared a health emergency of international concern on 23 July 2022. Before the global outbreak, monkeypox cases were mostly confined to central and west African countries, where this virus is prevalent. Close contact, mainly sexual contact, is supposed to be the main route of transmission, and it is remarkable that the incidence is higher in men who have sexual relationships with other men.

Case summary

A 40-year-old Caucasian man arrived at the emergency department complaining of oppressive epigastric pain extending to the chest after a diagnosis of pharyngitis, which was suspected to be caused by the human monkeypox virus. Based on the clinical symptoms, physical examination, serum cardiac biomarkers, and electrocardiographic findings, he was diagnosed with myopericarditis. The real-time PCR for human monkeypox in skin lesions, urine, plasma, and the oropharyngeal swab was positive. The peak of troponin I was 20.6 ng/ml, and the electrocardiogram showed an upward concavity in the ST segment in diffuse leads, which was in agreement with the previous diagnosis. The presence of edema, subepicardial, and myocardial late gadolinium enhancement, and increased values on T1 mapping in the cardiac MRI were in agreement with the diagnosis of myopericarditis. Antiviral treatment with tecovirimat was started with excellent tolerability. After 6 days, the patient recovered and was discharged.

Discussion

To our knowledge, this is one of the first reported cases of myopericarditis due to human monkeypox infection, which was confirmed by a cardiac MRI following modified Lake Louise criteria. The short span between the onset of the mucocutaneous symptoms and the myocardial damage suggests a pathogenic association. Furthermore, the active viral replication in plasma samples and the negative results on real-time PCR for other viruses support this clinical association.

Cardiovascular manifestations of monkeypox virus outbreak: An overview of the reported cases

BACKGROUND

Monkeypox (Mpox) is a zoonotic DNA virus related to the orthopoxvirus family that causes also smallpox infection.

OBJECTIVES

In this paper, we aimed to study the cardiovascular manifestations of Mpox.

METHOD

A literature databases search was conducted on 20th October 2022 and limited to 2022 (the new outbreak) to collect all the relevant papers that discussed cardiovascular manifestations in Mpox.

RESULTS

The literature included 6 cases of myocarditis, one case of pericarditis, one case of myopericarditis and one case of atrial fibrillation. Of total 6 cases with completed data, ECG results and troponin levels were abnormal in 5 cases while only three cases had abnormal ECHO and CMR results. In the four cases who undergone chest X-rays, only one patient had non-specific retro-cardiac opacities. All patients (9 cases) recovered well from their cardiovascular manifestations with no deaths and only 3 of them required ICU admission.

CONCLUSION

With the limited reported cases, we recommend performing cardiovascular examinations -in particular ECG and troponin levels- in order to exclude cardiovascular insult in patients with suspected Mpox -cardiovascular involvement. However, in our series the infection was mild in most patients with no mortality.