Ophthalmic Manifestations of the Monkeypox Virus: A Systematic Review and Meta-Analysis

Epidemiological and clinical characteristics of Peruvian patients with mpox: A systematic review and meta-analysis

BACKGROUND

Mpox has become a public health problem due to its rapid evolution and clinical variability. In Latin America, Peru ranks fifth in terms of the number of cases. The main objective of this study is to determine the epidemiological and clinical characteristics of Peruvian patients diagnosed with mpox, providing a detailed view of the situation of this affected population.

METHODS

A systematic review and meta-analysis of studies on mpox in Peru was carried out using ten databases and search tools (PubMed, Scopus, Web of Science, Embase, ScienceDirect, Google Scholar, Virtual Health Library, Scielo, Dimensions, and Epistemonikos) until August 22, 2024. The MeSH (Medical Subject Headings) terms used in the search were "mpox" and "Peru", combined with the logical operators AND and OR. Study quality was assessed using the Joanna Briggs Institute (JBI) assessment tool, and pooled estimates were generated using random-effects meta-analysis. Heterogeneity was assessed using the I² statistic. Statistical analysis was performed in R version 4.2.3, and the study was registered in PROSPERO (CRD42024582854).

RESULTS

A total of 150 articles were evaluated, of which 9 studies were included: four retrospective observational studies, four case series, and one case report, covering a total of 3960 Peruvian patients with mpox. The quality of the studies was moderate. The combined results show that 97% (95% CI: 96-98%; 3804 participants; 4 studies; I2 = 24%, p = 0.27) of the patients were male, 63% (95% CI: 57-68%; 2366 participants; 4 studies; I2 = 66%, p = 0.03) had HIV (human immunodeficiency virus), and 91% (95% CI: 83-97%; 2019 participants; 4 studies; I2 = 90%, p < 0.01) of these were receiving antiretroviral therapy. In addition, 61% (95% CI: 46-75%; 2295 participants; 4 studies; I2 = 95%, p < 0.01) identified as homosexual, and 17% (95% CI: 09-26%; 702 participants; 4 studies; I2 = 91%, p < 0.01) had a history of syphilis. The most common clinical manifestations were skin lesions (88%; 95% CI: 79-94%; 3114 participants; 4 studies; I2 = 92%, p < 0.01), lymphadenopathy (83%; 95% CI: 25-100%; 3623 participants; 2 studies; I2 = 100%, p < 0.01), anogenital rash (72%; 95% CI: 65-79%; 2657 participants; 3 studies; I2 = 74%, p = 0.02), fever (67%; 95% CI: 59-76%; 2587 participants; 4 studies; I2 = 86%, p < 0.01), and headache (52%; 95% CI: 47-57%; 1962 participants; 3 studies; I2 = 60%, p = 0.08).

CONCLUSION

This systematic review provides a detailed overview on the epidemiology and clinical characteristics of Peruvian patients with mpox, highlighting a high prevalence in men and a remarkable association with HIV coinfection. The data highlight the vulnerability of the affected population and the importance of a multidisciplinary medical approach, with emphasis on early diagnosis of the most common symptoms. The findings support the implementation of prevention strategies tailored to the most vulnerable populations, especially those with HIV coinfection, and the conduct of longitudinal studies to better understand the disease.

Ocular Manifestations of Mpox and Other Poxvirus Infections: Clinical Insights and Emerging Therapeutic and Preventive Strategies

Poxvirus infections, particularly those caused by the monkeypox virus, have emerged as significant public health threats. Ocular manifestations constitute a severe potential clinical complication associated with these infections, potentially resulting in permanent visual impairment in afflicted patients. This review aimed to examine the clinical spectrum of ocular manifestations associated with mpox and other poxvirus infections and to evaluate current management strategies alongside emerging therapeutic interventions and prevention strategies. A comprehensive literature search was performed across major databases to identify studies reporting ocular involvement in poxviral infections. Ocular involvement in poxviral infections ranges from mild conjunctivitis and eyelid lesions to severe keratitis with potential vision loss. Mpox-related ocular manifestations are more prevalent in unvaccinated and immunocompromised individuals. Although early antiviral intervention and supportive care are critical, clinical outcomes vary considerably across viral clades. Emerging evidence indicates that tecovirimat may reduce lesion severity, although its impact on accelerating recovery remains limited. Moreover, vaccine strategies, particularly the MVA-BN (JYNNEOS) vaccine, appear to decrease ocular complications, despite regional disparities in access and implementation. Ocular complications pose a significant clinical challenge in mpox and related poxviral infections. This review highlights the need for early diagnosis and integrated treatment approaches that combine antiviral therapy, supportive care, and targeted vaccination. Further research is essential to refine treatment protocols and assess the long-term outcomes in diverse patient populations.

The Risk Assessment of Uveitis After Monkeypox Diagnosis: A Multicenter Population-Based Study

The risks of uveitis development among monkeypox (MPOX) patients are unclear. To determine the uveitis risks after (MPOX) diagnosis. Population-based, retrospective cohort study used the TriNetX database and recruited those with and without MPOX diagnosis from January 1, 2016, to December 31, 2023. The non-MPOX cohort consisted of randomly selected control patients matched by covariates, including age, gender, ethnicity, race, relevant comorbidities, previous medications, and the inflammatory marker C-reactive protein. Statistical analysis on uveitis risk included hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated over 8 years (2016-2023). A separate analysis of the risk of uveitis among MPOX patients aged 20 years and older was also conducted. (MPOX) diagnosis, identified using electronic diagnostic codes. Cumulative incidence of new-onset uveitis. A total of 5449 MPOX patients of all ages (25.45% female; mean age at index 35.17 ± 15.70 years) and 5449 propensity-matched non-MPOX comparators (23.97% female; mean age at index 35.30 ± 15.91 years) were recruited from the TriNetX database. For both the overall MPOX patient population and the adult MPOX patients, the risk of uveitis was significantly higher compared to the non-MPOX cohort. This increased risk mainly happened in patients with anterior uveitis. Specifically, the hazard ratio for uveitis in all MPOX patients was 2.59 (95% CI: 1.40-4.79). Among MPOX patients aged 20 years or older, the hazard ratio for uveitis was 2.14 (95% CI: 1.17-3.94). There is a notable association between new-onset uveitis and patients with MPOX. Our real-world findings underscore the importance of being aware of the potential risk of anterior uveitis in this patient population.

Multi-organ clinical manifestations of Mpox: an umbrella review of systematic reviews

BACKGROUND

Mpox is a severe viral zoonosis that has emerged as a public health concern due to its potential for human-to-human transmission and severe illness. Understanding its clinical manifestations is crucial for effective management and control. Several systematic reviews have assessed various manifestations of Mpox. This umbrella review synthesizes evidence on Mpox's manifestations across different organ systems.

METHOD

We conducted an umbrella review, adhering to Joanna Briggs Institute (JBI) methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on systematic reviews of Mpox manifestations. We performed a literature search up to 25th September 2023, in databases like PubMed, Embase, and Web of Science. We included systematic reviews of observational studies, case reports, case series, or RCTs reporting any manifestations of Mpox in humans, focusing on a global scope. AMSTAR 2 was used to evaluate the quality of systematic reviews, and data has been synthesized in narrative and tabular manners.

RESULTS

A total of 25 systematic reviews were included, uncovering diverse manifestations of Mpox, such as cutaneous, cardiovascular, oral, ophthalmic, gastrointestinal, respiratory, and pregnancy-related. Cutaneous manifestations (up to 100%) were the most prevalent, featuring lesions and rashes. Constitutional symptoms of viral illness were reported in ~ 60% to > 85% of the cases. Significant respiratory symptoms were present in ~ 50% of cases overall. Headaches were the leading neurological symptom present in > 30%. Symptoms of gastrointestinal involvement ranged from 39% (oral lesions) with decreasing frequency to low diarrhea at ~ 5%, with proctitis percentages ranging from high teens to mid-twenties. Ophthalmic manifestations (6% but with wide variations among studies). Many primary studies included in the systematic reviews consisted of case reports and case series. A wide range of manifestations across different organ systems was observed. Negative outcomes for pregnancies were reported, but evidence is limited. Adverse cardiovascular and neurological outcomes were identified, though only a few studies provided insights into these findings.

CONCLUSION

Mpox exhibits diverse manifestations, impacting multiple organ systems, with substantial variations. The findings highlight the importance of ongoing, nuanced, and region-specific research and management strategies for Mpox. The reliance on case reports and series underscores the need for more high-quality, long-term studies to deepen our understanding and management of this significant public health concern.

Monkeypox-related ophthalmic disease

Monkeypox (Mpox) is an acute febrile rash illness caused by the Mpox virus. The ongoing international outbreak since mid-2022 has spread worldwide, including Taiwan. Ocular involvement in Mpox infection is uncommon, including external and ocular surface lesions. Here, we describe a man who developed unilateral blepharoconjunctivitis and preseptal cellulitis, followed by the appearance of skin symptoms 6 days after the ocular manifestations. Samples taken from his oropharynx and skin lesions tested positive for the Mpox virus through a polymerase chain reaction test. He was hospitalized for isolation with topical lubricant, antibiotic, and acyclovir eye ointment until the skin lesions healed. However, on the day of discharge, punctate epithelial keratitis was observed in the same eye. The corneal lesion also tested positive for the Mpox virus. His keratitis progressed to dendritic ulceration, and treatment with tecovirimat was initiated. Initially, his corneal ulcer responded well to tecovirimat, but 12 days later, it deteriorated along with cells in the anterior chamber. To treat his condition, low-dose steroid and ganciclovir eye drops were administered. Eventually, the patient experienced resolution of the corneal lesion, leaving a scar.

Clinical and Epidemiological Characteristics of the 2022 Mpox Outbreak in Spain (CEME-22 Study)

Background

We conducted a multicentric national study (SEIMC-CEME-22), to describe the clinical and epidemiological profile of the mpox outbreak in Spain, including the management of the disease.

Methods

This was a retrospective national observational study conducted by Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) and Foundation SEIMC-GESIDA. We included patients with a confirmed mpox diagnosis before 13 July 2022, and attended at the Spanish health network (the early phase of the outbreak). Epidemiological, clinical, and therapeutic data were collected.

Results

Of a total of 1472 patients from 52 centers included, 99% of them were cisgender men, mostly middle-aged, and 98.6% were residents in Spain. The main suspected route of transmission was sexual exposure, primarily among MSM. Occupational exposure was reported in 6 patients. Immunosuppression was present in 40% of patients, mainly due to human immunodeficiency virus (HIV). Only 6.5% of patients had been vaccinated against orthopoxvirus. Virus sequencing was performed in 147 patients (all B.1 lineage). Rash was the most frequent symptom (95.7%), followed by fever (48.2%), adenopathies (44.4%) myalgias (20.7%), proctitis (17%), and headache (14.7%). Simultaneously diagnosed sexually transmitted infections included syphilis (n = 129), gonococcal infection (n = 91), HIV (n = 67), chlamydia (n = 56), hepatitis B (n = 14), and hepatitis C (n = 11). No therapy was used in 479 patients (33%). Symptomatic therapies and antibiotics were used in 50% of cases. The most used therapy regimens were systemic corticoids (90 patients), tecovirimat (6 patients), and cidofovir (13 patients). Smallpox immunoglobulins were used in 1 patient. Fifty-eight patients were hospitalized, and 1 patient died.

Conclusions

Mpox outbreak in Spain affected primarily middle-aged men who were sexually active and showed a high rate of HIV infection. A range of heterogeneous therapeutics options was performed.

Monkeypox Patients Living with HIV: A Systematic Review and Meta-Analysis of Geographic and Temporal Variations

This index meta-analysis estimated the pooled prevalence of human immunodeficiency virus (HIV) among individuals with monkeypox (mpox) globally. We searched seven databases: PubMed, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane, for human studies published in English till 4 January 2023, as per International Prospective Register of Systematic Reviews (PROSPERO) registration protocol (CRD42022383275). A random effects regression model was used to estimate the pooled prevalence owing to high heterogeneity. The risk of bias in the included studies was assessed using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool. The systematic search yielded 677 articles; finally, 32 studies were found eligible for systematic review and 29 studies for meta-analysis. The pooled prevalence of HIV infection was 41% (95% confidence interval [CI], 35-48). All studies were rated as fair or good quality. Studies from Europe and North America reported a high prevalence of HIV infection among individuals with mpox- 41% (95% CI 33-49) and 52% (95% CI 28-76), respectively, while studies from Nigeria, Africa reported a relatively low prevalence of HIV infection of 21% (95% CI 15-26). A history of sexual orientation and sexual partners in the last 21 days must be taken from individuals with mpox to identify the potential source and contacts for quarantining and testing them.

Prevalence of mpox viral DNA in cutaneous specimens of monkeypox-infected patients: a systematic review and meta-analysis

Background

Human monkeypox (mpox) disease is a multicountry outbreak driven by human-human transmission which has resulted in an international public health emergency. However, there is limited evidence on the positivity rate of skin lesions for mpox viral DNA. We aim to fill this gap by estimating the pooled positivity rate of skin samples with mpox viral DNA from mpox patients globally.

Methods

In this systematic review and meta-analysis, seven databases and several preprint servers have been extensively searched until 17 January 2023 according to a prospectively registered protocol (PROSPERO: CRD42023392505). Articles including the positivity rate of skin samples with mpox viral DNA in mpox-confirmed patients were considered eligible. After a quality assessment, a random-effect meta-analysis was used for pooled prevalence. To explore and resolve heterogeneity, we used statistical methods for outlier detection, influence analysis, and sensitivity analysis.

Findings

Among the 331 articles retrieved after deduplication, 14 studies were finally included. The pooled positivity rate of the skin samples was 98.77% (95% CI: 94.74%-99.72%). After the removal of an influential outlier, I ² for heterogeneity dropped from 92.5% to 10.8%. Meta-regression did not reveal any significant moderator.

Conclusion/interpretation

The present findings reinforce that skin lesions act as a reservoir of mpox viral DNA and contribute to a high infectivity risk. This may be a prevailing basis of prompt transmission during the current multicountry outbreak and also needs further investigation. The present imperative outcome may benefit in producing valuable preventive and management procedures in an appropriate health strategy.

Pharmacological treatment and vaccines in monkeypox virus: a narrative review and bibliometric analysis

Mpox (earlier known as monkeypox) virus infection is a recognized public health emergency. There has been little research on the treatment options. This article reviews the specific drugs used to treat mpox virus infection and the vaccines used here. Instead of focusing on the mechanistic basis, this review narrates the practical, real-life experiences of individual patients of mpox virus disease being administered these medicines. We conducted a bibliometric analysis on the treatment of the mpox virus using data from several databases like PubMed, Scopus, and Embase. The research on this topic has grown tremendously recently but it is highly concentrated in a few countries. Cidofovir is the most studied drug. This is because it is indicated and also used off-label for several conditions. The drugs used for mpox virus infection include tecovirimat, cidofovir, brincidofovir, vaccinia immune globulin, and trifluridine. Tecovirimat is used most frequently. It is a promising option in progressive mpox disease in terms of both efficacy and safety. Brincidofovir has been associated with treatment discontinuation due to elevated hepatic enzymes. Cidofovir is also not the preferred drug, often used because of the unavailability of tecovirimat. Trifluridine is used topically as an add-on agent along with tecovirimat for ocular manifestations of mpox virus disease. No study reports individual patient data for vaccinia immune globulin. Though no vaccine is currently approved for mpox virus infection, ACAM 2000 and JYNNEOS are the vaccines being mainly considered. ACAM 2000 is capable of replicating and may cause severe adverse reactions. It is used when JYNNEOS is contraindicated. Several drugs and vaccines are under development and have been discussed alongside pragmatic aspects of mpox virus treatment and prevention. Further studies can provide more insight into the safety and efficacy of Tecovirimat in actively progressing mpox virus disease.