Mpox in Children and Adolescents: Epidemiology, Clinical Features, Diagnosis, and Management

Mpox in children and adolescents and contact follow-up in school settings in greater Paris, France, May 2022 to July 2023

BackgroundDuring the 2022 mpox outbreak in Europe, primarily affecting men who have sex with men, a limited number of cases among children and adolescents were identified. Paediatric cases from outbreaks in endemic countries have been associated with a higher likelihood of severe illness. Detailed clinical case descriptions and interventions in school settings before 2022 are limited.AimTo describe clinical characteristics of mpox cases among children (< 15 years) and adolescents (15-17 years) in the greater Paris area in France, and infection control measures in schools.MethodsWe describe all notified laboratory-confirmed and non-laboratory-confirmed cases among children and adolescents identified from May 2022 to July 2023, including demographic and clinical characterisation and infection control measures in school settings, i.e. contact tracing, contact vaccination, secondary attack rate and post-exposure vaccination uptake.ResultsNineteen cases were notified (13 children, 6 adolescents). Four adolescent cases reported sexual contact before symptom onset. Ten child cases were secondary cases of adult patients; three cases were cryptic, with vesicles on hands, arms and/or legs and one case additionally presented with genitoanal lesions. Five cases attended school during their infectious period, with 160 at-risk contacts identified, and one secondary case. Five at-risk contacts were vaccinated following exposure.ConclusionCases among children and adolescents are infrequent but require a careful approach to identify the source of infection and ensure infection control measures. We advocate a 'contact warning' strategy vs 'contact tracing' in order to prevent alarm and stigma. Low post-exposure vaccination rates are expected.

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.

Paediatric, maternal, and congenital mpox: a systematic review and meta-analysis

BACKGROUND

Although mpox has been detected in paediatric populations in central and west Africa for decades, evidence synthesis on paediatric, maternal, and congenital mpox, and the use of vaccines and therapeutics in these groups, is lacking. A systematic review is therefore indicated to set the research agenda.

METHODS

We conducted a systematic review and meta-analysis, searching articles in Embase, Global Health, MEDLINE, CINAHL, Web of Science, Scopus, SciELO, and WHO databases from inception to April 17, 2023. We included studies reporting primary data on at least one case of confirmed, suspected, or probable paediatric, maternal, or congenital mpox in humans or the use of third-generation smallpox or mpox vaccines, targeted antivirals, or immune therapies in at least one case in our population of interest. We included clinical trials and observational studies in humans and excluded reviews, commentaries, and grey literature. A pooled estimate of the paediatric case fatality ratio was obtained using random-effects meta-analysis. This study is registered with PROSPERO (CRD420223336648).

FINDINGS

Of the 61 studies, 53 reported paediatric outcomes (n=2123 cases), seven reported maternal or congenital outcomes (n=32 cases), two reported vaccine safety (n=28 recipients), and three reported transmission during breastfeeding (n=4 cases). While a subset of seven observational studies (21 children and 12 pregnant individuals) reported uneventful treatment with tecovirimat, there were no randomised trials reporting safety or efficacy for any therapeutic agent. Among children, the commonest clinical features included rash (86 [100%] of 86), fever (63 [73%] of 86), and lymphadenopathy (40 [47%] of 86). Among pregnant individuals, rash was reported in 23 (100%) of 23; fever and lymphadenopathy were less common (six [26%] and three [13%] of 23, respectively). Most paediatric complications (12 [60%] of 20) arose from secondary bacterial infections. The pooled paediatric case fatality ratio was 11% (95% CI 4-20), I2=75%. Data from 12 pregnancies showed half resulted in fetal death. Research on vaccine and immune globulin safety remains scarce for children and absent for pregnant individuals.

INTERPRETATION

Our review highlights critical knowledge gaps in the epidemiology, prevention, and treatment of mpox in children and pregnant individuals, especially those residing in endemic countries. Increased funding, international collaboration, and equitable research is needed to inform mpox control strategies tailored for at-risk communities in endemic countries.

FUNDING

None.

TRANSLATIONS

For the French, Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Overview of Vaginal Ulcerative Disease

Genital ulcers may be located on the vagina, penis, and anorectal or perineal areas and may be infectious or noninfectious. Vaginal ulcers affect patients of all ages and are commonly due to sexually transmitted infections, such as herpes simplex virus, the most common cause of genital ulcers in the United States. Non-sexually transmitted infections, such as Epstein-Barr virus, and other noninfectious causes, such as trauma, medications, and autoimmune disease, rarely can present with genital ulcers. Appropriate history, examination findings, and targeted testing must be used to correctly diagnose and treat vaginal ulcers. [Pediatr Ann. 2024;53(1):e10-e16.].

Mpox

ABSTRACT

Human mpox (formerly known as monkeypox) is a zoonotic disease that causes a smallpox-like infection in humans. The mpox virus, the causative agent of mpox, was first reported to cause human disease in a 9-month-old infant in the Democratic Republic of the Congo in 1970. Since that time, periodic outbreaks in primarily endemic regions have occurred, typically secondary to transmission from wildlife reservoirs. However, in May 2022, after a rapid rise in worldwide cases in largely nonendemic countries, the World Health Organization declared mpox a Public Health Emergency of International Concern. As of January 2022, more than 80,000 cases of mpox in nonendemic countries have occurred, and more than 25,000 cases in the United States alone. Most of these cases occurred in adults, with the highest frequency among men who had sex with men. Children and adolescents represented only 0.3% of US cases as of September 2022, with most infections in young children the result of direct contact with an infected household member. Although infection remains uncommon in US children and teens, pediatric emergency and urgent care providers should be aware of the clinical features, treatment, and prophylaxis of this important emerging infectious disease.

Detection of Asymptomatic Mpox Carriers among High-Ri Men Who Have Sex with Men: A Prospective Analysis

Mpox is traditionally considered a zoonotic disease with endemic circulation in Africa, but the 2022-2023 outbreak reached an unprecedented high number of cases in non-endemic countries, so that it was declared a public health emergency of international concern. The reasons for this extensive global spread, characterized by sexual transmission amongst men who have sex with men (MSM), have not been fully clarified. The existence of asymptomatic carriers with viable viral shedding might be an explanation and is under-debated after retrospective studies suggested that infection without symptoms might have a prevalence of 6.5%. We aimed to prospectively assess the presence of mpox infection in asymptomatic high-risk MSM using HIV pre-exposure prophylaxis and living with HIV. We selected individuals with no signs of active infection nor suggestive symptoms in the previous 21 days. Eligible individuals collected oral and anal swabs to undergo point-of-care testing for mpox and completed a 21-days follow-up. Seventy-two individuals were enrolled, and none tested positive for mpox infection nor developed symptoms during follow-up. We selected a high-risk population with a significant history of sexual exposure, but we failed to detect any asymptomatic infection. This observation might have important consequences in terms of contact management and epidemic control.

ChatDoctor: A Medical Chat Model Fine-Tuned on a Large Language Model Meta-AI (LLaMA) Using Medical Domain Knowledge

Objective The primary aim of this research was to address the limitations observed in the medical knowledge of prevalent large language models (LLMs) such as ChatGPT, by creating a specialized language model with enhanced accuracy in medical advice. Methods We achieved this by adapting and refining the large language model meta-AI (LLaMA) using a large dataset of 100,000 patient-doctor dialogues sourced from a widely used online medical consultation platform. These conversations were cleaned and anonymized to respect privacy concerns. In addition to the model refinement, we incorporated a self-directed information retrieval mechanism, allowing the model to access and utilize real-time information from online sources like Wikipedia and data from curated offline medical databases. Results The fine-tuning of the model with real-world patient-doctor interactions significantly improved the model's ability to understand patient needs and provide informed advice. By equipping the model with self-directed information retrieval from reliable online and offline sources, we observed substantial improvements in the accuracy of its responses. Conclusion Our proposed ChatDoctor, represents a significant advancement in medical LLMs, demonstrating a significant improvement in understanding patient inquiries and providing accurate advice. Given the high stakes and low error tolerance in the medical field, such enhancements in providing accurate and reliable information are not only beneficial but essential.

A global update of mpox (monkeypox) in children

PURPOSE OF REVIEW

Human mpox disease (formerly monkeypox) was first diagnosed in an infant in the Democratic Republic of the Congo in 1970. Mpox was rarely reported outside West and Central Africa until the global outbreak in May 2022. On 23 July 2022, the WHO declared mpox a public health emergency of international concern. These developments warrant a global update on pediatric mpox.

RECENT FINDINGS

Mpox epidemiology in endemic African countries has changed from predominantly affecting children under 10 years to adults 20-40 years old. This shift also applies to the global outbreak, where 18-44-year-old adult men who have sex with men are disproportionately affected. Furthermore, the proportion of children affected in the global outbreak is less than 2%, while children under 18 years constitute nearly 40% of cases in African countries. The highest mortality rates remain among both children and adults in African countries.

SUMMARY

Mpox epidemiology has shifted to adults and is affecting relatively few children in the current global outbreak. However, infants, immunocompromised children and African children are still at high risk of severe disease. Mpox vaccines and therapeutic interventions should be accessible to at-risk and affected children globally, especially to those living in endemic African countries.

Human Monkeypox Experience in a Tertiary Level Hospital in Milan, Italy, between May and October 2022: Epidemiological Features and Clinical Characteristics

Background: Monkeypox virus (mpxv) started to spread to Europe and North America at the beginning of the current outbreak in May 2022, and the World Health Organization (WHO) declared Human Monkeypox (mpox) as a public health emergency of international concern (PHEIC) in July 2022. The aim of this observational analysis is to describe demographical data, symptoms presentation and clinical course till outcome of individuals diagnosed with mpox, between May and October 2022, at our open-access Sexual Health Clinic in IRCCS San Raffaele Hospital in Milan, Italy. Methods: Among people who accessed our Sexual Health Clinic, we considered, as suspected diagnosis of mpox, individuals with consistent symptoms and epidemiological criteria. Following the physical examination, oropharyngeal, anal, genital and cutaneous swabs, plus plasma, urine and seminal fluid were collected as biological materials to detect mpxv DNA. We also performed a screening for sexually transmitted infections (STIs). Results: Overall, 140 individuals with mpox were included in this study. Median age was 37 (interquartile, IQR 33, 43) years old. Males were 137 (98%) and men who have sex with men (MSM) were 134 (96%). As risk factors, we detected travels abroad in 35 (25%) individuals and close contact with mpox cases in 49 (35%). There were 66 (47%) people living with HIV (PLWH). Most frequent symptoms were fever (59%), lymphadenopathy (57%), cutaneous (77%), genital (42%), anal (34%) and oral (26%) lesions, proctitis (39%), sore throat (22%) and generalized rash (5%). At mpox diagnosis, we also observed N. gonorrhoeae in 18 (13%) cases, syphilis in 14 (10%) and C. trachomatis in 12 (9%). Two (1%) people received a concomitant diagnosis of HIV infection. We attended to 21 (15%) complications, with nine (6%) cases of hospitalization including six (IQR 3,7) median hospital days. Forty-five (32%) patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs), 37 (26%) with antibiotics and eight (6%) with antiviral drugs. Conclusions: Similarly to other international cohorts, sexual transmission was most frequently present, and concomitant STIs were common. Symptoms were heterogenous, self-resolving and responsive to therapy. Hospitalization was necessary in few patients. There is uncertainty about the future development of mpox and further studies (e.g., potential disease reservoirs, other possible means of transmission, predictors of severe disease) are still needed.

Application of Artificial Intelligence Techniques for Monkeypox: A Systematic Review

Monkeypox or Mpox is an infectious virus predominantly found in Africa. It has spread to many countries since its latest outbreak. Symptoms such as headaches, chills, and fever are observed in humans. Lumps and rashes also appear on the skin (similar to smallpox, measles, and chickenpox). Many artificial intelligence (AI) models have been developed for accurate and early diagnosis. In this work, we systematically reviewed recent studies that used AI for mpox-related research. After a literature search, 34 studies fulfilling prespecified criteria were selected with the following subject categories: diagnostic testing of mpox, epidemiological modeling of mpox infection spread, drug and vaccine discovery, and media risk management. In the beginning, mpox detection using AI and various modalities was described. Other applications of ML and DL in mitigating mpox were categorized later. The various machine and deep learning algorithms used in the studies and their performance were discussed. We believe that a state-of-the-art review will be a valuable resource for researchers and data scientists in developing measures to counter the mpox virus and its spread.