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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 2022

See all articles by Eloy José Tarín-Vicente

Eloy José Tarín-Vicente

University Hospital 12 de Octubre - Dermatology Department

Manuel Agud-Dios

University Hospital 12 de Octubre - Dermatology Department

Andrea Alemany

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Maria Ubals

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Clara Suñer

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Andrés Antón

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron

Maider Arando

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron

Jorge Arroyo-Andrés

University Hospital 12 de Octubre - Dermatology Department

Lorena Calderón-Lozano

University Hospital 12 de Octubre - Dermatology Department

Cristina Casañ

Hospital Germans Trias i Pujol

José Miguel Cabrera

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Pep Coll

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Vicente Descalzo

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron

María Dolores Folgueira

University Hospital 12 de Octubre

Jorge N. García-Pérez

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron

Elena Gil-Cruz

University Hospital 12 de Octubre - Dermatology Department

Borja González-Rodríguez

University Hospital 12 de Octubre - Dermatology Department

Christian Gutiérrez-Collar

University Hospital 12 de Octubre - Dermatology Department

Águeda Hernández-Rodríguez

Hospital Germans Trias i Pujol

Paula López-Roa

University Hospital 12 de Octubre

María de los Ángeles Meléndez

University Hospital 12 de Octubre

Julia Montero-Menárguez

University Hospital 12 de Octubre - Dermatology Department

Irene Muñoz-Gallego

University Hospital 12 de Octubre

Sara Isabel Palencia-Pérez

University Hospital 12 de Octubre - Dermatology Department

Roger Paredes

Hospital Germans Trias i Pujol

Alfredo Pérez-Revilla

Instituto de Investigación Sanitaria Hospital "12 de Octubre" - Hospital Universitario 12 de Octubre

María Piñana

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron

Nuria Prat

Direcció d'Atenció Primària - Metropolitana Nord

Aída Ramirez

Hospital Germans Trias i Pujol

Ángel Rivero

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Carmen Alejandra Rubio-Muñiz

University Hospital 12 de Octubre - Dermatology Department

Martí Vall-Mayans

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Kevin Stephen Acosta-Velásquez

La Paz University Hospital

An Wang

University Hospital 12 de Octubre - Dermatology Department

Cristina Galván-Casas

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

Michael Marks

London School of Hygiene & Tropical Medicine - Faculty of Infectious and Tropical Diseases

Pablo L. Ortiz-Romero

University Hospital 12 de Octubre - Dermatology Department

Oriol Mitja

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section

More...

Abstract

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

Suggested Citation

Tarín-Vicente, Eloy José and Agud-Dios, Manuel and Alemany, Andrea and Ubals, Maria and Suñer, Clara and Antón, Andrés and Arando, Maider and Arroyo-Andrés, Jorge and Calderón-Lozano, Lorena and Casañ, Cristina and Cabrera, José Miguel and Coll, Pep and Descalzo, Vicente and Dolores Folgueira, María and García-Pérez, Jorge N. and Gil-Cruz, Elena and González-Rodríguez, Borja and Gutiérrez-Collar, Christian and Hernández-Rodríguez, Águeda and López-Roa, Paula and Meléndez, María de los Ángeles and Montero-Menárguez, Julia and Muñoz-Gallego, Irene and Palencia-Pérez, Sara Isabel and Paredes, Roger and Pérez-Revilla, Alfredo and Piñana, María and Prat, Nuria and Ramirez, Aída and Rivero, Ángel and Rubio-Muñiz, Carmen Alejandra and Vall-Mayans, Martí and Acosta-Velásquez, Kevin Stephen and Wang, An and Galván-Casas, Cristina and Marks, Michael and Ortiz-Romero, Pablo L. and Mitja, Oriol, Clinical Presentation and Virological Assessment of Confirmed Human Monkeypox Virus Cases in Spain : A Prospective Cohort Study. Available at SSRN: https://ssrn.com/abstract=4162718 or http://dx.doi.org/10.2139/ssrn.4162718

Eloy José Tarín-Vicente

University Hospital 12 de Octubre - Dermatology Department ( email )

Manuel Agud-Dios

University Hospital 12 de Octubre - Dermatology Department ( email )

Andrea Alemany

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Maria Ubals

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Clara Suñer

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Andrés Antón

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron ( email )

Maider Arando

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron ( email )

Jorge Arroyo-Andrés

University Hospital 12 de Octubre - Dermatology Department ( email )

Lorena Calderón-Lozano

University Hospital 12 de Octubre - Dermatology Department ( email )

Cristina Casañ

Hospital Germans Trias i Pujol ( email )

José Miguel Cabrera

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Pep Coll

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Vicente Descalzo

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron ( email )

María Dolores Folgueira

University Hospital 12 de Octubre ( email )

Jorge N. García-Pérez

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron ( email )

Elena Gil-Cruz

University Hospital 12 de Octubre - Dermatology Department ( email )

Borja González-Rodríguez

University Hospital 12 de Octubre - Dermatology Department ( email )

Christian Gutiérrez-Collar

University Hospital 12 de Octubre - Dermatology Department ( email )

Águeda Hernández-Rodríguez

Hospital Germans Trias i Pujol ( email )

Paula López-Roa

University Hospital 12 de Octubre ( email )

María de los Ángeles Meléndez

University Hospital 12 de Octubre ( email )

Julia Montero-Menárguez

University Hospital 12 de Octubre - Dermatology Department ( email )

Irene Muñoz-Gallego

University Hospital 12 de Octubre ( email )

Sara Isabel Palencia-Pérez

University Hospital 12 de Octubre - Dermatology Department ( email )

Roger Paredes

Hospital Germans Trias i Pujol ( email )

Alfredo Pérez-Revilla

Instituto de Investigación Sanitaria Hospital "12 de Octubre" - Hospital Universitario 12 de Octubre ( email )

Madrid
Spain

María Piñana

Autonomous University of Barcelona - Hospital Universitari Vall d'Hebron ( email )

Nuria Prat

Direcció d'Atenció Primària - Metropolitana Nord ( email )

Aída Ramirez

Hospital Germans Trias i Pujol ( email )

Ángel Rivero

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Carmen Alejandra Rubio-Muñiz

University Hospital 12 de Octubre - Dermatology Department ( email )

Martí Vall-Mayans

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Kevin Stephen Acosta-Velásquez

La Paz University Hospital ( email )

Spain

An Wang

University Hospital 12 de Octubre - Dermatology Department ( email )

Cristina Galván-Casas

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

Michael Marks

London School of Hygiene & Tropical Medicine - Faculty of Infectious and Tropical Diseases ( email )

Pablo L. Ortiz-Romero

University Hospital 12 de Octubre - Dermatology Department ( email )

Oriol Mitja (Contact Author)

Hospital Universitari Germans Trias i Pujol - Skin Neglected Diseases and Sexually Transmitted Infections Section ( email )

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