A total of 528 confirmed cases of monkeypox infection from five continents, 16 countries, and 43 clinical sites were included in this series (shape 1). The demographic and clinical characteristics of infected persons are summarized in Table 1.
Overall, 98% of those affected were gay or bisexual men, and 75% were white. The average age was 38 years. A total of 41% of the subjects had HIV infection, and in the vast majority of these subjects, HIV infection was well controlled; 96% of those infected with HIV were receiving ART, and in 95% the viral load was less than 50 copies per milliliter (Table 2). Prior exposure prophylaxis was used in the month prior to presentation in 57% of subjects who were not known to have HIV infection.
Panel (a) shows the development of skin lesions in a person with monkeypox; Pictures a1 and a2 show lesions on the face, pictures b1 through b3 show a penile lesion, and pictures c1 and c2 show a lesion on the forehead. PCR status is indicated if available. IM stands for intramuscular, and MSM stands for MSM. Panel B shows oral and perioral lesions (image A, umbilical lesions around the mouth; Image B, vesicular lesion around the mouth at day 8, PCR positive; Image C, ulcers on the left corner of the mouth at day 7, PCR positive; Image D, tongue ulcers; image e, lesion of the tongue on day 5, PCR positive; and images f, g and h, pharyngeal lesions on day 0, 3 and 21, respectively, PCR positive on day 0 and 3 and negative on day 21). Panel C shows perianal, anal and rectal lesions (image A, anal and perianal lesions on day 6, PCR positive; images B and C, rectal and anal lesions in one person, PCR positive; image D, perianal ulcers, PCR positive; image E , anal lesions; s f, perianal lesion on day 3, PCR positive; image g, perianal lesions on day 3, PCR positive; and image h, perianal ulcer on day 2, PCR positive).
The characteristics of monkeypox in this case series are summarized in Table 3. Skin lesions are observed in 95% of subjects (Figure 2). The most common anatomical site was the anogenital region (73%); torso, arms or legs (55%); face (25%); Palms and soles (10%). A wide range of skin lesions have been described (see Clinical Image Library on the Web), including macular, pustular, vesicular and scaly lesions, and lesions in multiple stages were simultaneously present. Among the subjects with skin lesions, 58% had lesions described as vesicular-pustular. The number of lesions varied greatly, with most subjects having fewer than 10 lesions. A total of 54 subjects were presented with only one genital ulcer, highlighting the potential for misdiagnosis as a different type of STI. Mucosal lesions were reported in 41% of subjects. Anal mucosal involvement was reported as a presenting symptom in 61 subjects; This involvement has been associated with anal pain, proctitis, tenesmus, or diarrhea (or a combination of these symptoms). Oropharyngeal symptoms were reported as initial symptoms in 26 subjects; These symptoms included pharyngitis, pharyngitis, epiglottitis, and lesions of the mouth or tonsils. In 3 subjects, mucosal conjunctival lesions were among the present symptoms. Common systemic features during the course of the disease include fever (62%), lethargy (41%), myalgia (31%) and headache (27%), which are symptoms that precede a generalized rash; Lymphadenopathy was also common (56%).
The initial presentation feature and subsequent cutaneous and systemic feature sequences (taken as free text) showed significant variance. The most common presentation was primary cutaneous lesions or lesions, primarily in the anogenital region, body (trunk or extremities), or face (or a combination of these sites), with increasing number of lesions over time and with or without systemic features (see timelines series). in Clinical Image Library on the Web). Due to the observational nature of this case series, variability in time of presentation, and reliance on clinical records, a clear chronology of potential exposure and symptoms was available for only 30 subjects. Of these 30 subjects, 23 subjects had a clearly defined exposure event, with median time from exposure to onset of symptoms 7 days (range, 3 to 20). Lesions with prodrome occurred in 17 out of 30 subjects; However, isolated anogenital or oral lesions were observed (13 subjects). The median time from onset of symptoms to the first positive PCR result was 5 days (range, 2 to 20), and the median time from the appearance of the first skin lesion to the appearance of additional skin lesions was 5 days (range, 2 to 11) (See Clinical Image Library on the Web.) In subjects for whom follow-up PCR test data were available, the last time point at which the lesion remained positive was 21 days after symptom onset.
The clinical presentation was similar between HIV-infected and non-HIV-infected subjects. Clinical characteristics of people with HIV infection are shown in Table 2. Associated STIs were reported in 109 of the 377 people (29%) who were tested, with gonorrhea, chlamydia, and syphilis present in 8%, 5%, and 9%, respectively, of those tested.
The suspected means of transmission of monkeypox virus as mentioned by the doctor was close sexual contact in 95% of the subjects. It was not possible to confirm the transmission of infection through sexual contact. A sexual history was recorded in 406 out of 528 people; Of these 406 people, the average number of sexual partners in the previous 3 months was 5, 147 (28%) reported traveling abroad in the month prior to diagnosis, and 103 (20%) attended large gatherings (>30 people), such as Pride events. Overall, 169 (32%) were known to have visited on-site sex within the past month, and 106 (20%) reported engaging in “chemsex” (i.e., sex associated with drugs such as mephedrone and crystal methamphetamine) in the same period.
A total of 70 people (13%) were hospitalized. The most common reasons for admission were pain management (21 subjects), mostly acute anal pain, and treatment of soft tissue infection (18). Other causes included acute pharyngitis limiting oral intake (5 people), treatment of eye lesions (2), acute kidney injury (2), myocarditis (2), and infection control purposes (13). There was no difference in the frequency of admission according to HIV status. Three new cases of HIV infection have been identified.
Two types of serious complications have been reported: one case of epiglottitis and two cases of myocarditis. Epiglottitis occurs in an HIV-positive person who has a CD4 cell count of less than 200 per cubic millimeter; The person was treated with tecovirimat and fully recovered. Cases of myocarditis were self-limited (<7 days) and resolved without antiviral therapy. One occurred in an HIV-positive person with a CD4 cell count of 780 per cubic millimeter, and one occurred in a non-HIV-infected person. No deaths were reported.
In all, 5% of the 528 people received treatment specifically for monkeypox. Drugs given included intravenous or topical cidofovir (in 2% of subjects), teicovermate (2%), and xenia immune globulin (less than 1%).
The health setting of the initial presentation reflected referral patterns and included sexual health or HIV clinics, emergency departments, dermatology clinics, and less commonly primary care. A positive PCR result was most commonly obtained from skin or anogenital lesions (97%); Other sites were sampled less frequently. The percentages of positive PCR results were 26% for nasopharyngeal samples, 3% for urine samples, and 7% for blood samples. Semen was tested in 32 subjects from five clinical sites and was PCR-positive in 29 subjects (4 of these cases were previously reported).19) (Table 4).