First reports of monkeypox and varicella-zoster virus coinfection in the global human monkeypox outbreak in 2022

Detection of mpox and other orthopoxviruses using a lateral flow device as a point-of-care diagnostic

In 2022, the World Health Organization declared the worldwide outbreak of mpox to be a public health emergency of international concern. The causative monkeypox virus (MPXV) belonged to clade IIb and is transmitted through sexual contact with a low case fatality rate (0.1%), which, together with under-detection, all contributed to a rapid global spread particularly within the MSM (men who have sex with men) community. As MPXV clade II remains circulating worldwide, a new outbreak of the more fatal clade I disease has been declared in Central and East Africa, and remains uncontrolled in part due to the lack of point-of-care (POC) diagnostics for rapid decisions on treatment and self-isolation. To address the lack of POC solutions for mpox, we have designed and evaluated an orthopoxvirus-specific lateral flow device (LFD) that could be used for the diagnosis of mpox. Using an LFD comprising four monoclonal antibodies against the A27 protein, we demonstrate sensitivity to 3 × 105 pfu/mL. This sensitivity is expected to be sufficient for the detection of MPXV from lesion sites and may also be sufficient for other sample types such as saliva and urine. We found that the presence of guanidinium thiocyanate, a common ingredient in inactivating viral transport media, masked the LFD antigen, resulting in false negatives. POC diagnosis of mpox may be possible using an LFD to reduce delays arising from sample shipment to centralized laboratory testing facilities. In order to achieve this, our work demonstrates that an LFD-optimized buffer is required, as the sample collection buffer may have a detrimental impact on sensitivity for clinical material.IMPORTANCEMpox cases have dramatically increased both in traditionally monkeypox virus endemic countries and also worldwide. This increase comes at a time when immunity derived from smallpox vaccination is no longer available. Diagnosis of mpox is complicated due to both disease presentation and the availability of local diagnostic laboratories. The availability of a point-of-care diagnostic tool such as an lateral flow device (LFD) would play an important role to both diagnose and prevent onward transmission. This manuscript provides developers and assessors with key data for defining true sensitivity and specificity of a successful LFD in addition to buffer conditions for sample collection.

A case of herpes zoster secondary to monkeypox in a young man

A 19-year-old young man presented with prodromal symptoms including fever and sore throat, followed by the development of scattered rashes in the perianal and penile regions. Monkeypox (MPX) was confirmed using polymerase chain reaction (PCR) of lesions. On the third day after complete resolution of the initial rash, the patient developed a new rash, which was diagnosed as secondary herpes zoster (HZ). Therefore, clinicians should not only focus on the accurate diagnosis of monkeypox, but also be alert to secondary herpes zoster.

Ecthyma amidst the global monkeypox outbreak: A key differential? -A case series

Background

Ecthyma is a deeper form of impetigo involving the epidermis and dermis causing ulcerative plaques. Pathogens commonly responsible for the disease (group A beta-hemolytic streptococcus and Staphylococcus aureus) typically afflicts children, presenting during early stages with skin lesions that can closely resemble other vesicular and ulcerative dermatoses, such as those observed in mpox infection. The ongoing global outbreak of monkeypox has escalated the urgency for clinicians to accurately differentiate between these conditions due to their overlapping dermatological manifestations. Through this series, we intend to demonstrate the diverse clinical presentations of ecthyma observed in non-endemic regions, which may closely mimic those of monkeypox.

Case presentation

The first case describes a 12- year-old male with a history of atopic dermatitis, presenting with a vesicular rash initially suspected to be monkeypox. However, diagnosis via skin punch biopsy and cultures revealed ecthyma. The second case involved an 18-year-old male with acute, rapidly progressing ulcerated lesions and systemic symptoms. Differential diagnosis included toxic shock syndrome and necrotizing fasciitis, but histopathological findings confirmed ecthyma. The third case featured a 55-year-old woman with rapidly developing skin lesions on her hand, resolved through empirical antibiotic therapy, further confirming the diagnosis.

Conclusion

misdiagnosis and thus, delayed treatment of ecthyma leads to severe unfavourable outcomes. Given its rare occurrence yet fatal potential, and the current global vigilance due to the monkeypox outbreak, it is vital for healthcare providers to include ecthyma in the differential diagnosis of necrotic and ulcerative skin lesions.

Clinical presentation and molecular diagnosis of a possible Mpox virus and Varicella zoster virus co-infection in an adult immunocompetent Filipino: a case report

We report the first travel-related case of a possible Mpox-Varicella zoster virus (VZV) co-infection in the Philippines, a country that is endemic for Varicella but non-endemic for Mpox. A 29-year-old Filipino, female, with a travel history to Switzerland and with no prior history of VZV infection sought consultation due to rashes. She presented with multiple papular, pustular, and vesicular skin lesions, some with umbilication and with irregular borders, on the face, neck, trunk, inguinal area, upper extremities, and right leg. She also had bilateral submandibular and post-auricular lymphadenopathies. Tzanck smear exhibited viral cytopathic effects. She tested positive for Mpox infection (Clade II) and Varicella infection via quantitative real-time polymerase chain reaction (qPCR) tests but with a high CT value obtained from the Mpox PCR. Shotgun metagenomic sequencing (mNGS) successfully recovered sequences from the Varicella zoster virus which corroborated with the high viral load detected using qPCR. In contrast, shotgun mNGS was not able to generate a Mpox consensus sequence due to very few reads mapped to the Mpox virus reference sequence, which raised the question if there was the presence of a true Mpox-Varicella co-infection in our patient. Nevertheless, systemic and topical acyclovir was given to the patient. She was discharged and continued home isolation for 30 days from the rash onset. Strategies have been formed by the country's healthcare facilities to properly identify Mpox infection. However, Mpox co-infection with other viral diseases presented a challenge in the proper diagnosis of our patient. This prompted a high index of suspicion and the usage of suitable diagnostic tests. With proper clinical evaluation and utilization of appropriate diagnostic tests, we were able to diagnose the first Filipino patient with a possible Mpox and Varicella zoster virus co-infection.

The successful treatment of mpox with brincidofovir in renal transplant recipients-a report of 2 cases

An mpox outbreak was declared in July 2022 by the world health organization (WHO). It causes a mild self-limiting disease however; in immunosuppressed hosts, it tends to cause severe disseminated infection. Most cases of mpox in sold organ transplant (SOT) recipients reported in the literature were treated with tecovirimat. Here we report two cases of severe disseminated mpox infection in renal transplant recipients that were successfully treated with brincidofovir. Both patients were discharged from the hospital with no immediate significant side effects from brincidofovir reported until the submission of this report.

Mpox outbreak in Rio de Janeiro, Brazil: A translational approach

Mpox is a zoonotic disease historically reported in Africa. Since 2003, limited outbreaks have occurred outside Africa. In 2022, the global spread of cases with sustained interhuman transmission and unusual disease features raised public health concerns. We explore the mpox outbreak in Rio de Janeiro (RJ) state, Brazil, in an observational study of mpox-suspected cases from June to December 2022. Data collection relied on a public healthcare notification form. Diagnosis was determined by MPXV-PCR. In 46 confirmed cases, anti-OPXV IgG was determined by ELISA, and seven MPXV genomes were sequenced. A total of 3095 cases were included, 816 (26.3%) with positive MPXV-PCR results. Most positive cases were men in their 30 s and MSM. A total of 285 (34.9%) MPXV-PCR+ patients live with HIV. Eight were coinfected with varicella-zoster virus. Anogenital lesions and adenomegaly were associated with the diagnosis of mpox. Females and individuals under 18 represented 9.4% and 5.4% of all confirmed cases, respectively, showing higher PCR cycle threshold (Ct) values and fewer anogenital lesions compared to adult men. Anti-OPXV IgG was detected in 29/46 (63.0%) patients. All analyzed sequences belonged to clade IIb. In RJ state, mpox presented a diverse clinical picture, represented mainly by mild cases with low complication rates and prominent genital involvement. The incidence in females and children was higher than usually reported. The observation of a bimodal distribution of Ct values, with few positive results, may suggest the need to review the diagnostic criteria in these groups.

A Case of Varicella Zoster and Mpox Coinfection in a Patient Living With HIV

ABSTRACT

We present a case of recurrent, cutaneous mpox with coinfection of disseminated varicella zoster in an immunocompromised patient with poorly controlled HIV. This case demonstrates the importance of maintaining a high index of suspicion for mpox despite prior infection and vaccination, as suboptimal immune response is possible in immunocompromised patients, and also noting the potential for coinfection necessitating timely diagnosis and appropriate testing.

Differences and similarities between Monkeypox and Chickenpox in children during an outbreak

INTRODUCTION

Herein, we described cases of children under 16 years old suspected to be infected with Monkeypox virus (MKPV) and diagnosed with chickenpox in public hospitals of Marseille, south of France.

MATERIAL AND METHODS

We conducted a retrospective study from March 23rd, 2022 to October 20th, 2022 in our institution of results of MKPV DNA and varicella-zoster virus (VZV) DNA detection by PCR performed on cutaneous lesions swabs collected from children <16 years old.

RESULTS

None of the cutaneous swabs collected from 14 children were positive for MKPV DNA. In contrast, 30/168 (17 %) cutaneous swabs collected from children were positive for VZV DNA. Of these 30 VZV-positive children, 7 had been suspected of MKPV infection because of their atypical rash, due to the location of the lesions and the chronology of their appearance.

DISCUSSION

As in our cohort, pediatric cases of the 2022 Monkeypox outbreak in non-endemic developed countries have been very rare. This variant of MKPV does not normally spread easily and requires very close physical contact between an infected person (skin lesions, bodily fluids or respiratory droplets) and another person to be transmitted. It will nevertheless be a question of remaining vigilant as not to ignore the possibility of close contact or sexual transmission of Monkeypox in a child, or the possibility of a new and more contagious variant.

CONCLUSION

It is difficult to differentiate Monkeypox infection from other infections associated with rashes, it is important to remember that viruses change as well as their forms of presentation.

No Varicella Zoster Virus Infection among Mpox Cases in Antwerp, Belgium

Several studies in tropical settings have reported that ∼20% of patients infected with Monkeypox virus (MPXV) also tested polymerase chain reaction (PCR) positive for Varicella zoster virus (VZV). Researchers have hypothesized that VZV infection predisposes to monkeypox (mpox), or vice versa, or that MPXV triggers the reactivation of VZV. We tested samples for VZV from a cohort of patients infected with clade IIb MPXV diagnosed between May 23 and October 14, 2022 in Antwerp, Belgium. Leftover DNA extracts of skin lesion samples from 108 mpox patients were tested with in-house PCR for VZV. No VZV infections were found. The absence of concurrent VZV-MPXV infections in our cohort indicates that VZV did not cocirculate in the population at risk for MPXV during the Belgian 2022 outbreak, but also that MPXV does not commonly trigger reactivation of latent VZV in adult men.

A meta-analysis and mapping of global mpox infection among children and adolescents

Monkeypox (mpox) is a significant health concern affecting children and adolescents globally. This systematic review and meta-analysis aims to synthesise the available evidence on the proportion of children and adolescents affected by the mpox virus. A comprehensive search was conducted in seven electronic databases (PubMed, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane) to identify the original reports on mpox cases in children and adolescents till 15 January 2023. Descriptive reports on probable or laboratory-confirmed mpox in children and adolescents (0-17 years old) were considered eligible. Studies not providing separate data for the above age group and case-control studies were excluded. The primary outcome was pooled proportion of mpox cases among children and adolescents. Proportion meta-analysis and heterogeneity between studies were determined using a restricted maximum likelihood estimator, and a random-effects model was fitted to the data. Sensitivity analysis and subgroup analysis were also conducted. A drapery plot was also provided as a complementary figure to the forest plot. The protocol was prospectively registered with PROSPERO (CRD42023392475). A total of 440 studies were identified, of which 37 were included in the review and 25 in the meta-analysis (62,701 participants with 3306 children and adolescents). The pooled proportion of children and adolescents was 0.46 (95% CI: 0.30-0.63, I2 :100%). The proportion of children and adolescents was significantly lower (p < 0.001) in the ongoing pandemic 0.04 (95% CI: 0.00-0.32) than before 2022 0.62 (95% CI: 0.49-0.74). The meta-regression showed that the higher the study's sample size, the lower the proportion of children among the mpox cases. Both overall and subgroup heterogeneity were high. Adolescents and children below 5 years are commonly affected by the ongoing pandemic. In conclusion, the high proportion of children affected by the mpox virus highlights the need for increased research and targeted interventions to prevent and control the spread of the virus in this population.