Portal de Periódicos da CAPES

Monkeypox: a new (sexually transmissible) epidemic?

2022; Wiley; Volume: 36; Issue: 12 Linguagem: Inglês

10.1111/jdv.18424

1468-3083

Miguel Alpalhão, Joana Vieitez Frade, Diogo de Sousa, João Patrocínio, Pedro Garrido, Catarina Correia, Cláudia Brazão, Dora Mancha, Maria José Borrego, Paulo Filipe,

Bacillus and Francisella bacterial research

An outbreak of monkeypox has emerged, with more than 2000 cases confirmed across the globe. While this condition, caused by the Monkeypox virus, a member of the Orthopoxvirus genus, is usually considered a zoonosis,1 we may be facing a sexually transmissible infection (STI), with yet uncertain consequences. In Portugal, we are seeing many suspected cases a day, most of which have been confirmed. At our department, we have had more than 20 confirmed cases, most of which in individuals with concomitant human immunodeficiency virus infection. The typical presentation we are observing is illustrated by the case of a 43-year-old man, with a 3-day history of painful umbilicated vesicles and ulcers localized to the perianal and genital areas (Fig. 1), with no prodromal symptoms. Centimetric elastic inguinal adenopathies were found, but no extrapelvic skin lesions or adenomegalies were present. He had engaged in unprotected receptive and insertive anal intercourse over the past 2 weeks, but the history was otherwise unremarkable. We collected samples from the vesicles, which identified Monkeypox virus in polymerase chain reaction. Before this outbreak, these patients would be probably diagnosed with an ulcerative STI: genital herpes, syphilis or chancroid. However, the umbilicated papulo-vesicles are suggestive of poxviridae infection, as seen in molluscum contagiosum. Another diagnostic clue is the absence of a typical herpetiform figuration, where vesicles are frequently seen packed closed together. Different from syphilis chancre, these lesions are painful, and unlike chancroid, Monkeypox features vesicles, but they may progress to ulcers later on and not be found. These cases contrast with the description of Monkeypox in endemic areas, where a prodromal state of fever, malaise and adenopathies is followed by a disseminated vesico-pustular eruption, usually starting on the face or trunk, with centrifugal progression, not unlike varicella.1, 2 From our experience, about half the patients deny or have very mild systemic symptoms. Interestingly, colleagues from Spain have reported a case of Monkeypox presenting with proctitis and disseminated maculopapular eruption in a man who engaged in high-risk sexual intercourse, which further supports the hypothesis that Monkeypox may indeed be a STI.3 Unlike other STI, Monkeypox spreads through large respiratory droplets, making Monkeypox a public health concern. Although usually self-limited, Monkeypox may be fatal in up to 10% of the patients, and no drug has proven effective in clinical trials.4 Monkeypox should be diagnosed early on to allow isolation of infected patients. As these cases have been identified mostly in men who have sex with men (MSM), targeted communication to this community should be promoted, to raise awareness. The use of condom is of unknown efficacy to prevent transmission, but extrapolating from other viral STI,5 it will not be nearly 100% effective, and counsel for abstinence from casual intercourse during the outbreak may be offered as a preventive measure. Healthcare workers are also at increased risk for Monkeypox.6 Thus, the use of personal protection equipment is paramount to prevent transmission. FFP2 masks may be used when collecting samples or dealing with suspected cases, until the risk for respiratory transmission is clarified. As smallpox was eradicated, vaccination against this disease, which grants cross-protection against Monkeypox, has not be carried in younger cohorts. A new generation smallpox vaccine containing a live modified vaccine virus (vaccinia Ankara) has been approved in the United States for monkeypox prevention and is currently approved in Europe, but only for smallpox prevention. If cases continue to rise, vaccination should be offered to those at highest risk: MSM and healthcare workers. Physicians should consider this rare dermatosis in the differential diagnosis of genital ulcers, and we may be standing at the front line of yet another epidemic crisis. There are no conflicts of interest to declare. The patient in this manuscript has given written informed consent to the publication of his case details. Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.