Two cases of Monkeypox virus infection without detectable
cutaneous/mucosal lesions
Giulia Ciccarese1, Giorgia
Brucci2,3, Antonio Di Biagio2,3,
Francesco Drago4,
Bruno Caccianotti5, Sergio Lo
Caputo5, Gaetano Serviddio6, Teresa
Santantonio5
1Unit of Dermatology, Department of Medical and
Surgical Sciences, University of Foggia, Viale Pinto 1, 71122, Foggia,
Italy;
2Infectious Diseases Unit, San Martino Policlinico
Hospital, IRCCS for Oncology and Neurosciences, Largo R. Benzi, 10,
16132 Genoa, Italy;
3Department of Health Sciences (DiSSal), University of
Genova, Via Pastore, 1, 16132 Genova, Italy;
4Unit of Dermatology, San Martino Policlinico
Hospital, IRCCS for Oncology and Neurosciences, Largo R. Benzi, 10,
16132 Genoa, Italy;
5Clinic of Infectious Diseases, Department of Clinical
and Surgical Sciences, University of Foggia, Viale Pinto, 1, 71122
Foggia, Italy;
6C.U.R.E. (University Centre for Liver Disease
Research and Treatment), Liver Unit, Department of Medical and Surgical
Sciences, University of Foggia, Viale Pinto 1, 71122, Foggia, Italy.
Email addresses of the co-authors:giorgia.brucci@libero.it;
antonio.dibiagio@hsanmartino.it;
francescodrago007@gmail.com;
bcaccianotti@ospedaliriunitifoggia.it;
sergio.locaputo@unifg.it;
gaetano.serviddio@unifg.it;
teresa.santantonio@unifg.it
Corresponding author : Giulia Ciccarese, MD, PhD, Unit of
Dermatology, Department of Medical and Surgical Sciences, University of
Foggia, Viale Pinto 1, 71122, Foggia, Italy. Telephone: +390881736093.
Email address: giulia.ciccarese@unifg.it
Keywords: Monkeypox virus infection, anal pain, risky
behaviors, sexually transmitted infections.
Data availability statement: data available on reasonable request.
Funding statement: this research did not receive founds.
Conflict of interest: none
Patient consent statement: obtained.
Dear Editor,
in our case series of 16 human Monkeypox virus (MPX) infected patients
diagnosed from 1th July until 31thAugust 2022 in the Dermatology Unit and in the Infectious Disease Unit
of the San Martino Hospital, Genoa, Italy1, two
patients had no detectable cutaneous/mucosal manifestations at the time
of MPX diagnosis.
The first patient was a 37-year-old Italian homosexual man presenting to
the Infectious Disease Unit for the pre-exposure prophylaxis (PrEP)
against HIV follow-up appointment. He had been complaining of anal pain
without anal bleeding or secretions for 5 days and admitted risky sexual
behaviors (unprotected sex with casual partners) in the previous two
weeks, when he had travelled to Indonesia and France. His stable
partner, a 24-year-old Italian homosexual man, complained of sore throat
and reported the same risky behaviors. He had not travelled abroad in
the last month.
At physical examination, the patients had not visible cutaneous/mucosal
lesions. They performed a complete sexually transmitted infections
(STIs) screening including serology for T.pallidum infection,
human immunodeficiency virus (HIV), hepatitis B and C viruses, anal,
urethral and oropharyngeal swabs for the search of DNA ofChlamydia Trachomatis , Neisseria gonorrhoeae, Mycoplasma
hominis, Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma
parvum, Trichomonas vaginalis by polymerase chain reaction (PCR) and,
lastly, anal and oropharyngeal swabs for the search of MPX DNA by PCR,
as previously described2,3. The laboratory
investigations resulted all negative, except for the detection of MPX
DNA at the oropharyngeal and anal swabs, that resulted positive in both
sites and in both patients. The clinical presentation of these patients
could be misdiagnosed with other STIs, especially with non-gonococcal
proctitis and pharyngitis. Indeed, we suggest considering MPX infection
in all at-risk patients presenting with traditional or atypical STIs
signs/symptoms to avoid incorrect diagnosis.
Unlike the patient with MPX virus infection manifesting as single
cutaneous lesion that we recently described4,
these two patients had not
detectable cutaneous/mucosal lesions but only signs/symptoms of systemic
involvement. Indeed, MPX virus traditionally causes a systemic
infection: once acquired through close contact with skin/mucosal
lesions, large respiratory droplets or fomites, the virus replicates at
the inoculation site, then it spreads to the local lymph nodes and
subsequently to the bloadstrem (initial viremia), causing the viral
spread to other organs. These infection phases represent the viral
incubation period, lasting 7-14 days. Signs/symptom onset correlates
with a secondary MPX viremia corresponding to 1-2 days of prodromal
signs/symptoms (mainly fever and lymphadenopathy) before appearance of
skin/mucosal lesions5. Noteworthy, the MPX systemic
spread during the acute infection represents a potential threat to the
safety of blood transfusion and organ
transplantation6.
According to one of the largest case series describing MPX related signs
and symptoms, presentation of MPX
infection without skin/mucosal lesions accounts for about 5% of all
cases7. We can speculate that in such cases, as in our
patients and in those described by Quattri et al.8,
the cutaneous/mucosal MPX viral load was so low to cause only localized,
single or even undetectable lesions. Unfortunately, we were not able to
quantitatively assess the MPX viral load in the swabs that resulted
positive nor in the patient’s blood samples to confirm this hypothesis.
In conclusion, MPX infection can represent a diagnostic challenge,
especially when it occurs as a single cutaneous lesion of the
genito-anal site4,8 or with acute anal or
oropharyngeal pain in absence of associated cutaneous/mucosal lesions.
Physicians should be aware of the possible atypical and scant
manifestations of the disease and, in case of high clinical suspicion,
should not exclude MPX infection even if cutaneous/mucosal lesions are
undetectable.
Authors’ contributions : Giulia Ciccarese, Giorgia Brucci:
conceptualization, methodology, writing-original draft; Francesco Drago,
Antonio Di Biagio: investigation, resources; Bruno Caccianotti, Sergio
Lo Caputo, Teresa Santantonio, Gaetano Serviddio: writing review and
editing, supervision.