Monkeypox and pan-resistant Campylobacter spp infection in Entamoeba histolytica and Chlamydia trachomatis re-infection in a man who have sex with men
2022; Elsevier BV; Volume: 85; Issue: 4 Linguagem: Inglês
10.1016/j.jinf.2022.06.028
ISSN1532-2742
AutoresAngelo Roberto Raccagni, Davide Mileto, Diana Canetti, A. Tamburini, Alberto Rizzo, Elena Bruzzesi, Antonella Castagna, Silvia Nozza,
Tópico(s)Bacillus and Francisella bacterial research
Resumo•An MSM was diagnosed with monkeypox (MPX) and concurrent STI and STEIs.•Sexual intercourse might be the predominant way of transmission of MPX.•Physicians should be aware of MPX among individuals with a previous history of STIs.•Presence of a concurrent STI should not rule out MPX infection and vice versa.•Anoscopy might be helpful in revealing unnoticed MPX lesion. Dear editor,In this journal Heskin et al. recently presented the cases of two men who have sex with men (MSM) who acquired monkeypox (MPX) infection suggesting that sexual intercourse is becoming the predominant transmission route of the new MPX outbreak [1Heskin J. Belfield A. Milne C. Brown N. Walters Y. Scott C. et al.Transmission of monkeypox virus through sexual contact - a novel route of infection.J Infect. 2022; (S0163-4453(22)00335-8)Abstract Full Text Full Text PDF Scopus (33) Google Scholar]. Multiple cases of MPX infection have also been reported in Italy, predominantly among MSM [2Antinori A. Mazzotta V. Vita S. Carletti F. Tacconi D. Lapini L.E. et al.Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy.Euro Surveill. 2022; 27 (May 2022)2200421Crossref PubMed Scopus (103) Google Scholar]. Co-infection with other sexually transmitted infections (STIs) has also been documented, corroborating the hypothesis of sexual transmission [2Antinori A. Mazzotta V. Vita S. Carletti F. Tacconi D. Lapini L.E. et al.Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy.Euro Surveill. 2022; 27 (May 2022)2200421Crossref PubMed Scopus (103) Google Scholar].We present the case of a 42-years-old MSM who was receiving HIV pre-exposure prophylaxis (PrEP) since 2017 at the Infectious Diseases Department of San Raffaele Hospital, Milan, Italy. He was diagnosed with MPX infection in June 2022, together with a pan-resistant Campylobacter spp infection and an Entamoeba histolytica and Chlamydia trachomatis proctitis re-infection.Over the last 2 years, he has been diagnosed with multiple STIs and sexually transmitted enteric infections (STEI), including chlamydia and Entamoeba histolytica (Table 1).Table 1Previous STIs over 5 years of follow-up.YearSTIs / STEIsMonth 0Chlamydia proctitisMonth 2Chlamydia pharyngitisMonth 13Gonorrhea proctitisMonth 19Gonorrhea urethritisMonth 24Chlamydia proctitisMonth 28Entamoeba histolyticaMonth 29Chlamydia proctitisMonth 35Gonorrhea proctitisMonth 36GiardiasisMonth 37Genital Herpes SimplexMonth 41Gonorrhea proctitisMonth 44Chlamydia proctitisAbbreviations: STI: sexually transmitted infection; STEI: sexually transmitted enteric infection Open table in a new tab No travel history to MPX endemic areas or previous smallpox vaccination was reported.He went to Gran Canaria, Spain 30 days before symptoms onset, where a huge MPX outbreak is thought to have occurred [3Soriano V. Corral O. International outbreak of monkeypox in men having sex with men.AIDS Rev. 2022; Crossref Scopus (4) Google Scholar]. He reported engaging in multiple condomless receptive and insertive intercourse with >20 partners in the month preceding symptoms onset. Moreover, a non-sexual close contact with a confirmed MPX case occurred 5 days prior to symptoms onset, although the individual had a negative oropharyngeal swab for MPX and only rectal lesions, in the absence of cutaneous involvement, suggesting that the infection was not acquired by the contact with the confirmed MPX case. Furthermore, we believe that MPX infection was locally acquired in Italy, given the long delay in symptoms onset following return from Gran Canaria, although we cannot exclude a prolonged incubation period [4Miura F. van Ewijk C.E. Backer J.A. Xiridou M. Franz E. Op de Coul E. et al.Estimated incubation period for monkeypox cases confirmed in the Netherlands.Euro Surveill. 2022; 27 (May 2022)Crossref PubMed Scopus (19) Google Scholar].He presented to our clinic complaining diarrhea, tenesmus and two single atypical small (2 × 2 mm) non-vesicular erythematous cutaneous and perianal lesions, which were non-tender. No other systemic symptoms or cutaneous involvement were documented. Upon high-resolution anoscopy examination several rectal ulcers were documented, suggesting that this was the primary infection site (Fig. 1). Real-time PCR (RealStar® Orthopoxvirus PCR Kit 1.0 – altona DIAGNOTICS) targeting variola virus and non-variola Orthopoxvirus species (cowpox, monkeypox, raccoonpox, camelpox, vaccinia virus) showed the presence of non-variola DNA on serum, rectal and cutaneous swabs (cycle thresholds: 37, 35 and 27, respectively). A specific Real-Time PCR targeting Monkeypox virus DNA (Liferiver - SHANGHAI ZJ BIO-TECH CO., LTD) subsequently confirmed the MPX virus infection. Plasma, urines, seminal fluid and an oropharyngeal swab tested negative for MPX. A full STIs and STEIs screening was performed to rule out differential diagnoses: this revealed concurrent Chlamydia trachomatis proctitis, 1st line therapy pan-resistant Campylobacter spp (azithromycin, ciprofloxacin, clarithromycin and doxycycline resistant) and Entamoeba histolytica infection. Abdominal ultrasound ruled out hepatic involvement. Entamoeba histolytica re-infection was treated with tinidazole, Chlamydia trachomatis proctitis with doxycycline and stool cultures were repeated, documenting spontaneous clearance of Campylobacter spp infection, with resolution of diarrhea in 7 days. Lastly, serum, plasma, seminal fluid, urines and cutaneous, oropharyngeal and rectal swabs were collected after 10 days from MPX diagnosis, without further evidence of presence of non-variola Orthopoxvirus DNA.We observed the case of MPX diagnosis in an MSM with concurrent STI and STEIs diagnoses.This case corroborates the idea that sexual intercourse could be the predominant way of transmission of MPX. Firstly, the individuals reported multiple condomless intercourse with different partners and a broad clinical history of previous STIs. Moreover, MPX involvement was mostly at the rectal site, as documented by anoscopy, without systemic symptoms. Presence of a concurrent STI which might explain the observed lesions or symptoms should not rule out MPX infection among suspected cases, given the risk of co-infection. Anoscopy examination might be helpful in revealing unnoticed lesion among individuals reporting receptive intercourse. We believe that physicians should be aware of MPX among individuals with a previous history of STIs, who report high-risk sexual behaviors. Moreover, given a MPX diagnosis we suggest performing among all individuals a full STI screening, considering also STEIs if diarrhea is present. We detected a Campylobacter spp infections which was resistant to all 1st line therapies, which highlights how antimicrobial resistance is a major concern referring to both STIs and STEIs. Dear editor, In this journal Heskin et al. recently presented the cases of two men who have sex with men (MSM) who acquired monkeypox (MPX) infection suggesting that sexual intercourse is becoming the predominant transmission route of the new MPX outbreak [1Heskin J. Belfield A. Milne C. Brown N. Walters Y. Scott C. et al.Transmission of monkeypox virus through sexual contact - a novel route of infection.J Infect. 2022; (S0163-4453(22)00335-8)Abstract Full Text Full Text PDF Scopus (33) Google Scholar]. Multiple cases of MPX infection have also been reported in Italy, predominantly among MSM [2Antinori A. Mazzotta V. Vita S. Carletti F. Tacconi D. Lapini L.E. et al.Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy.Euro Surveill. 2022; 27 (May 2022)2200421Crossref PubMed Scopus (103) Google Scholar]. Co-infection with other sexually transmitted infections (STIs) has also been documented, corroborating the hypothesis of sexual transmission [2Antinori A. Mazzotta V. Vita S. Carletti F. Tacconi D. Lapini L.E. et al.Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy.Euro Surveill. 2022; 27 (May 2022)2200421Crossref PubMed Scopus (103) Google Scholar]. We present the case of a 42-years-old MSM who was receiving HIV pre-exposure prophylaxis (PrEP) since 2017 at the Infectious Diseases Department of San Raffaele Hospital, Milan, Italy. He was diagnosed with MPX infection in June 2022, together with a pan-resistant Campylobacter spp infection and an Entamoeba histolytica and Chlamydia trachomatis proctitis re-infection. Over the last 2 years, he has been diagnosed with multiple STIs and sexually transmitted enteric infections (STEI), including chlamydia and Entamoeba histolytica (Table 1). Abbreviations: STI: sexually transmitted infection; STEI: sexually transmitted enteric infection No travel history to MPX endemic areas or previous smallpox vaccination was reported. He went to Gran Canaria, Spain 30 days before symptoms onset, where a huge MPX outbreak is thought to have occurred [3Soriano V. Corral O. International outbreak of monkeypox in men having sex with men.AIDS Rev. 2022; Crossref Scopus (4) Google Scholar]. He reported engaging in multiple condomless receptive and insertive intercourse with >20 partners in the month preceding symptoms onset. Moreover, a non-sexual close contact with a confirmed MPX case occurred 5 days prior to symptoms onset, although the individual had a negative oropharyngeal swab for MPX and only rectal lesions, in the absence of cutaneous involvement, suggesting that the infection was not acquired by the contact with the confirmed MPX case. Furthermore, we believe that MPX infection was locally acquired in Italy, given the long delay in symptoms onset following return from Gran Canaria, although we cannot exclude a prolonged incubation period [4Miura F. van Ewijk C.E. Backer J.A. Xiridou M. Franz E. Op de Coul E. et al.Estimated incubation period for monkeypox cases confirmed in the Netherlands.Euro Surveill. 2022; 27 (May 2022)Crossref PubMed Scopus (19) Google Scholar]. He presented to our clinic complaining diarrhea, tenesmus and two single atypical small (2 × 2 mm) non-vesicular erythematous cutaneous and perianal lesions, which were non-tender. No other systemic symptoms or cutaneous involvement were documented. Upon high-resolution anoscopy examination several rectal ulcers were documented, suggesting that this was the primary infection site (Fig. 1). Real-time PCR (RealStar® Orthopoxvirus PCR Kit 1.0 – altona DIAGNOTICS) targeting variola virus and non-variola Orthopoxvirus species (cowpox, monkeypox, raccoonpox, camelpox, vaccinia virus) showed the presence of non-variola DNA on serum, rectal and cutaneous swabs (cycle thresholds: 37, 35 and 27, respectively). A specific Real-Time PCR targeting Monkeypox virus DNA (Liferiver - SHANGHAI ZJ BIO-TECH CO., LTD) subsequently confirmed the MPX virus infection. Plasma, urines, seminal fluid and an oropharyngeal swab tested negative for MPX. A full STIs and STEIs screening was performed to rule out differential diagnoses: this revealed concurrent Chlamydia trachomatis proctitis, 1st line therapy pan-resistant Campylobacter spp (azithromycin, ciprofloxacin, clarithromycin and doxycycline resistant) and Entamoeba histolytica infection. Abdominal ultrasound ruled out hepatic involvement. Entamoeba histolytica re-infection was treated with tinidazole, Chlamydia trachomatis proctitis with doxycycline and stool cultures were repeated, documenting spontaneous clearance of Campylobacter spp infection, with resolution of diarrhea in 7 days. Lastly, serum, plasma, seminal fluid, urines and cutaneous, oropharyngeal and rectal swabs were collected after 10 days from MPX diagnosis, without further evidence of presence of non-variola Orthopoxvirus DNA. We observed the case of MPX diagnosis in an MSM with concurrent STI and STEIs diagnoses. This case corroborates the idea that sexual intercourse could be the predominant way of transmission of MPX. Firstly, the individuals reported multiple condomless intercourse with different partners and a broad clinical history of previous STIs. Moreover, MPX involvement was mostly at the rectal site, as documented by anoscopy, without systemic symptoms. Presence of a concurrent STI which might explain the observed lesions or symptoms should not rule out MPX infection among suspected cases, given the risk of co-infection. Anoscopy examination might be helpful in revealing unnoticed lesion among individuals reporting receptive intercourse. We believe that physicians should be aware of MPX among individuals with a previous history of STIs, who report high-risk sexual behaviors. Moreover, given a MPX diagnosis we suggest performing among all individuals a full STI screening, considering also STEIs if diarrhea is present. We detected a Campylobacter spp infections which was resistant to all 1st line therapies, which highlights how antimicrobial resistance is a major concern referring to both STIs and STEIs. S.N. visited the individual and contributed to writing the article. A.R.R. contributed to writing the article. E.B., D.C. and A.C. contributed to the reviewing of the article. D.M. and A.R. coordinated virologic activities and performed PCR tests for MPX. A.M.T. performed anoscopy examination. All authors have read and agreed to the published version of the manuscript. None. None.
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