Statements
Data Availability: Data is available upon request from the
corresponding author.
Funding statement: No funding was obtained
Conflict of interest : None
Ethical statement: Institutional Review Board exemption was
granted for this study.
Monkeypox is a zoonotic disease caused by a double-stranded DNA virus
known as Family Poxviridae , subfamily Chordopoxvirinae ,
genus Orthopoxvirus , species Monkeypoxvirus.1,2 Recently, the World Health Organisation
responded to concerns of social stigma and discrimination by
recommending to change the name of the infection to
Mpox.3 Mpox (MPX) circulated in West and Central
Africa with small, short-lived outbreaks outside of
Africa.4,5 Starting in May of 2022, a global outbreak
of MPX was reported, which grew to over 85,765 cases in 110 countries,
as of February 13, 2023.6,7,8 This report summarizes
here the authors’ MPX clinical experience at an academic medical center
serving the New York Metropolitan area, including the Hudson Valley and
New York City.
The first case of MPX was seen in at the institution in June 2022 in a
patient with recent travel to a large social event for gay and bisexual
men in Florida. He presented with multiple vesicular lesions and scabs
in the genital area, extremities, and trunk along with inguinal
lymphadenopathy, fever, chills and fatigue. Since this initial case, 23
other patients were diagnosed with MPX; demographic and clinical
description are described in Table 1. All patients with suspicious
dermatologic findings had MPX PCR done on dry swabs of skin lesions sent
to the New York State or commercial reference laboratory.
Symptoms of MPX described by the patients included fatigue, myalgia,
fever, chills, body aches, headaches, skin rashes, genital rashes
(Figure 1, panels A-H) and constipation which correlate with those
frequently described in the literature.9 Less common
presentations included rectal abscess (2), peritonsillar abscess (1),
acute urethritis (2) and proctitis (8). The abscesses were treated with
antibiotics since they were suspected to be due to bacterial
superinfection. Proctitis was an especially painful complication,
observed in 8 of the 24 patients. All patients with proctitis had
constipation, 4 had hematochezia, and 2 had urinary retention. Three of
the 8 patients with proctitis required hospitalization for pain
management.
All patients who presented with MPX were evaluated for tecovirimat
treatment through the expanded access investigational new drug protocol
managed by the Center for Disease Control (CDC). Ten patients met the
CDC inclusion criteria for therapy.10,11 and received
fourteen-day courses of tecovirimat. Clinical response to tecovirimat
was observed with resolution of symptoms in 5 patients within 48 – 72
hours of therapy and in another 3 within 96 hours. No patients noted any
side effects attributable to tecovirimat.
One HIV positive patient with a recent absolute CD4 count of 611
cells/dL and a suppressed HIV viral load showed a very slow response to
his initial course of tecovirimat. Within 4 days of ending therapy, the
patient developed new painful anal ulcers that were Herpes Simplex Virus
1/2 (HSV) PCR negative and MPXV PCR positive. He failed a 5-day course
of valacyclovir and thus was given a second 14-day course of tecovirimat
with complete resolution of his recurrent symptoms. Four weeks after the
last dose of tecovirimat, this patient underwent sigmoidoscopy, which
did not show any residual ulcers or signs of anal strictures. Another
patient who had diabetes and was HIV negative presented with very
tender, purulent buttock nodules (Figure 1, panels F-H) and proctitis.
He was hospitalized for pain management. By the time he started
tecovirimat, he had had 10 days of enuresis and 4 days of urinary
retention. This patient’s urethritis resolved with two days of
tecovirimat and he passed stool after three days of therapy.
Five patients developed symptoms of MPX and tested positive by PCR after
their initial dose of JYNNEOS (Smallpox and Monkeypox Vaccine, Live,
Non-replicating). One patient presented with rash the day of
vaccination. Two patients, who had known close contact with MPX
developed rash within a day of vaccination. Two more patients reported
MPX rash onset 4 and 5 days after vaccination, respectively. None of the
patients who developed rash after vaccination had severe disease.
Mpox involving mucosal surfaces can cause significant morbidity by
eliciting painful mucositis of the pharynx, urethra, and anus. This can
lead to urinary retention and severe constipation. In our cohort, we
noted 11 patients with mucositis, 2 of whom presented with mucositis
prior to rash onset. In addition, we noted significant purulent lesions
involving the skin or mucosal surfaces that require antiviral therapy to
hasten recovery without empiric antibiotics.
Mpox point mutations have been identified by the CDC during this Mpox
outbreak but the clinical significance has not been elucidated
yet.12,13 In our case series, a good response with
resolution of symptoms on tecovirimat in all but 2 patients were noted.
As described above, 1 patient had rebound anal ulcers a few days after
cessation of tecovirimat and the second patient had little to no
response to tecovirimat. It is unknown at this time if the recurrent
infection was due to a resistant strain or failure of the immune system
to clear the infection.
Five patients developed Mpox after the initial dose of JYNNEOS. Since 2
of the 5 developed rash within a day and the other 2 within 5 days, it
is likely that these patients were harboring MPX at the time of
vaccination given that the average incubation period is 7
days.14 Similarly, other studies reported that 4-10%
of cases developed MPX despite post-exposure vaccination with an average
occurrence of 5 days post immunization which supports the theory that
protective immunity has not developed during that time
span.15,16
New York City experienced a rapid, high-impact outbreak of MPX which
overflowed into the local counties, taxing medical resources throughout
the New York Metropolitan area. Control of this current Mpox outbreak
was possible due to timely onboarding of accurate diagnostics,
availability of an investigational drug, and mass
vaccination.17 This case series sheds light on the
MPX’s characteristic clinical features of presentation, response to
treatment, and clinical outcomes. Uncommon presentations included severe
urethritis, suppurative ulcerations, abscess formation, and MPX
infection after post-exposure vaccination. Slow response to tecovirimat
or recurrence of symptoms was not uncommon.