Doctors have identified new clinical symptoms of monkeypox

(ORDO NEWS) — The MD team detailed a series of monkeypox cases in 528 people from four regions: Europe, the Americas, the Western Pacific and the Eastern Mediterranean.

An international team of clinicians from the SHARE-net group has published detailed statistics on the manifestations, clinical course and outcomes of monkeypox, cases of which until last April were rare outside the Black Continent, where it is endemic.

Now the virus is spreading around the world: the day before yesterday, WHO chief Tedros Adhanom Ghebreyesus reported 14,000 cases in 70 countries, five people died. The vast majority of patients are men under 40 who have sex with members of the same sex.

So, the authors of the report, posted yesterday in the New England Journal of Medicine , spoke about 528 patients from 16 countries.

The monkeypox virus was detected in them from April 27 to June 24 this year: 84 (16%) live in North and South America, 444 (84%) live in Europe, Israel or Australia. Each participating medical center where these patients were treated filled out a special structured spreadsheet with case histories.

Of the 528 people, 98% were gay/bisexual, 75% were white, and the median age was 38; 99% are male, and one person described himself as transgender/non-binary.

In 41%, HIV was already confirmed, but this had almost no effect on the clinical picture. Almost all (96%) of these patients were on antiretroviral therapy. In addition, several dozen men had either gonorrhea, or chlamydia, or syphilis.

95% of monkeypox-infected monkeys had a rash, 73% had lesions on the genitals, 55% on the torso, arms and legs, 25% on the face, and 10% on the hands and feet. The nature of these rashes was varied: vesiculopustular (in 58% of patients), macular, pustular, vesicular and cortical, in most cases several types occurred simultaneously – up to ten pieces.

In 41% of patients, the mucosa was affected, and in 61 people the rash was localized in the anorectal region and was considered the main symptom of monkeypox. Inflammation was accompanied by anorectal pain, proctitis, tenesmus (false painful urge to defecate or urinate), diarrhea.

Oropharyngeal symptoms were present at the onset of the disease in 26 people: among them – pharyngitis, odynophagia (swallowing disorder), epiglottitis (inflammation of the epiglottis) and damage to the oral cavity or tonsils. Three patients were diagnosed with conjunctivitis.

Before the rash appeared, patients complained of fever (62%), lethargy (41%), myalgia (31%), headache (27%), swollen lymph nodes (56%). Twenty-nine of the 32 men who submitted seminal fluid for analysis found DNA from the monkeypox virus in it.

The incubation period in 23 people who had a clear clinical picture was seven days (from three to 20). On average, it took five days (from two to 20) from the onset of symptoms to the first positive PCR test result, the same amount of time it took from the moment the first skin lesion developed to their active spread. The symptoms persisted for up to three weeks.

A total of 70 patients (13%) were hospitalized, most often requiring pain medication due to severe anorectal pain.

Other causes include superinfection of soft tissues, severe pharyngitis, which made it almost impossible to eat, eye damage, acute renal failure, myocarditis. Three people were first diagnosed with HIV at the same time as monkeypox.

Only 5% of 528 people received specific monkeypox treatment: they were prescribed cidofovir (2%), tecovirimat (2%), and vaccinia immunoglobulin (less than 1%). There were no lethal outcomes.

Doctors have identified new clinical symptoms of monkeypox
Skin lesions on the face caused by monkeypox

According to scientists, 95% of the study participants (504 people) caught monkeypox precisely as a result of close sexual contact: this is confirmed both by the DNA of the virus in the semen and by the primary lesions of the genital mucosa, anal canal and oral cavity, which probably served as the site of inoculation.

Only three were infected through household contact, four through close non-sexual contact. For 3% (17 people), the route of transmission is unknown. Only 26% (135 people) confirmed that they had definitely been in contact with an already sick person.

“Sexual anamnesis was registered in 406 out of 528 people, among them the number of sexual partners in the previous three months, on average, exceeded five people; 147 patients (28%) traveled abroad within a month prior to diagnosis, and 103 (20%) attended mass events with more than 30 people, such as pride events.

It is known that 169 (32%) went to places for sex in the previous month, and 106 (20%) practiced chemsex in the same period, ”the authors of the report said.

As the researchers note, the clinical picture they describe has some distinctive features that have not been previously reported.

So, doctors did not distinguish mucous or rectal manifestations of the disease and did not state that at first a single lesion may occur. Previous guidelines considered monkeypox in the context of any “unusual” rash, but did not cover the full range of skin symptoms.

“Single skin lesions on the genitals, hands and feet can easily lead to misdiagnosis of syphilis and other sexually transmitted infections. At the same time, we registered concomitant laboratory-confirmed STIs in 29% of the examined individuals,” the researchers added.

Monkeypox in its endemic regions tends to be self-limited, with a mortality rate of 1-10% depending on the strain (Congo and West African). The disease usually begins with a fever, followed by multiple papular, vesiculopustular, and ulcerative facial/body lesions and marked lymphadenopathy.

Complications include pneumonitis, encephalitis, corneal inflammation, secondary bacterial infections. Children and immunocompromised people, including those with HIV, are at risk of death.

However, according to scientists, today’s global outbreak could change the situation due to the weakening of immunity to smallpox, the lifting of anti-COVID measures, the resumption of international travel and various public events that involve promiscuity, among other things.

On the basis of phylogenetic analysis, experts assume that the monkeypox virus circulated undetected for some time outside areas where it was endemic, probably often masquerading as other sexually transmitted infections.

“While the current outbreak heavily affects gay and bisexual men and other men who have sex with members of the same sex, monkeypox is no more a ‘gay disease’ than it is an ‘African disease’. This can happen to anyone. We identified nine heterosexual men with monkeypox.

And we urge everyone to be vigilant when examining unusual severe rashes, especially when they are combined with systemic symptoms, so as not to miss the diagnosis in heterosexual individuals, ”summed up the authors of the report.

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