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Clinical Presentation and Virological Assessment of Confirmed Human Monkeypox Virus Cases in Spain : A Prospective Cohort Study
27 Pages Posted: 18 Jul 2022More...
Background: In May 2022, England reported various cases of infection with monkeypox virus, which rapidly spread throughout other countries in Europe. Early reports of this monkeypox outbreak suggest atypical presentations of the infection; therefore, we aimed to investigate the clinical and virological characteristics of infected patients.
Methods: In this observational, prospective, multi-center study, we included confirmed cases of monkeypox in three sexual health clinics in Madrid and Barcelona from May 9 to June 29, 2022. Suspected patients were offered systematically triple-site (i.e., lesion, anal and oropharynx swabs) monkeypox real-time-RT-PCR testing. Laboratory-confirmed cases were assessed for demographic, epidemiological and sexual behavior information, clinical presentation and progression, and virological outcomes.
Results: Monkeypox infection was confirmed in 181 cases; 166 (91·7%) identifying as men who have sex with men (MSM). Median age was 37 years (IQR 31-42), 175 (96·7%) of 181 were male, 32 (17·7%) had received smallpox vaccination and 73 (40·3%) were people living with HIV. The median incubation time was 7 days (IQR 5-10). All patients presented with skin lesions; 141 (77·9%) of 181 patients had lesions in the anogenital region, and 78 (43·1%) in the oral and perioral region. 70 (38·7%) of 181 patients had complications requiring medical treatment: 45 (24·9%) of 181 had a proctitis, 19 (10·5%) tonsillitis, and 6 (3·3%) bacterial skin abscess. 176 (98·9%) of 178 swabs from skin lesion collected tested positive, and so did 82 (73·9%) of 111 throat swabs. Viral load was higher in skin lesion swabs than in pharyngeal specimens (CT-value 22 vs 33, p <0·001). 108 (65·1%) of 166 MSM reported anal-receptive intercourse; these individuals had longer incubation periods (8 vs 6 days), higher rate of systemic symptoms before the rash (62·0% vs 27·6%) and presented more frequently with proctitis (32·9% vs 6·9%) than MSM who did not engage in this type of sexual practice. Overall, the median time from the onset of lesions to the formation of a dry crust was 10 days (IQR 7-13).
Conclusions: In our study cohort, monkeypox caused genital, perianal, and oral lesions and complications like proctitis and tonsillitis. Because of the variability of clinical presentations clinicians should have a low threshold for suspicion of the disease. Compared to pharyngeal swabs, lesion swabs show much higher viral loads, suggesting close contact is likely to be the dominant transmission route in the current outbreak.
Funding Information: None.
Declaration of Interests: On behalf of the authors of this paper that we have no relevant conflicts of interest to declare.
Ethics Approval Statement: The study was approved by the Ethics Committee of the Hospital Germans Trias i Pujol and oral informed consent was obtained from all patients and recorded in their medical files. Written consent for anonymized publication of images was individually sought from participants and documented.
Keywords: monkeypox, clinical, presentations, virological assesment, route of transmission
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