Treatment and prevention of monkeypox

Monkeypox is a zoonosis that is spread mainly through direct contact with fluids and skin lesions of infected people with vesicles still active. Although the virus was isolated for the first time in 1958 and the first human case was identified in a child in 1970, in the Democratic Republic of the Congo, the disease has progressively increased its incidence in Africa reaching in May 2022 sustained transmission outside this continent. As it is a newly introduced virus in our health system, it is necessary to learn the epidemiological pattern in a different environment from that of traditionally endemic areas and to know the available antiviral treatments, as well as the prophylactic measures that could be considered, knowing that as a virus emerging in our regions, scientific evidence is still limited. There are antivirals that have been shown, in animal models, to effectively combat the disease with very good clinical tolerance. This disease has also forced us to review the characteristics of smallpox vaccines, because they have shown a protective effect against monkeypox. For this reason, it is important to have a document that compiles all the scientific information published in this regard.

Mpox Pain Management with Topical Agents: A Case Series

With the recent spread in monkeypox cases, continuous efforts are made to manage the disease efficiently. Pain at the site of monkeypox lesions and in areas of skin breakdown can be severe. The origin of pain is likely neuropathic. The Centers for Disease Control and Prevention (CDC) has issued general guidelines to control pain with non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentin, and topical agents such as corticosteroids and lidocaine. Guidelines circulated by the World Health Organization (WHO) suggest acetaminophen, tramadol, opioids, and/or topical lidocaine for symptomatic pain management. No first line agent with proven beneficial effect has been recommended in these patients. We present two patients' painful experiences with Monkeypox and suggest lessons learned.

Clinical, molecular, and histological characteristics of severely necrotic and fatal mpox in HIV-infected patients

BACKGROUND

This case series of 5 patients with severely necrotic mpox highlights the predominantly necrotic nature of lesions seen in cases of severe mpox as shown by skin and lung biopsy, as well as the extensive dissemination of the infection, as shown by polymerase chain reaction (PCR) assessment in different body sites.

CASE PRESENTATIONS

Patients were male, the median age was 37, all lived with HIV (2 previously undiagnosed), the median CD4+ cell count was 106 cells/mm3, and 2/5 were not receiving antiretroviral treatment. The most common complication was soft tissue infection. Skin and lung biopsies showed extensive areas of necrosis. Mpox PCR was positive in various sites, including skin, urine, serum, and cerebrospinal fluid. The initiation of antiretroviral treatment, worsened the disease, like that seen in immune reconstitution syndrome. Three patients died due to multiple organ failure, presumably associated with mpox since coinfections and opportunistic pathogens were ruled out.

CONCLUSIONS

Severely necrotic manifestations of mpox in people living with advanced and untreated HIV are related to adverse outcomes.

Monkeypox: Virology, laboratory diagnosis and therapeutic approach

Monkeypox infection outbreaks have been observed sporadically in Africa, usually as a result of interaction with wildlife reservoirs. The genomes of the new strain range in size from 184.7 to 198.0 kb and are identified with 143-214 open reading frames. Viral cores are rapidly carried on microtubules away from the cell's perimeter and deeper into the cytoplasm once the virus and cell membranes fuse. Depending on the kind of exposure, patients with monkeypox may experience a febrile prodrome 5-13 days after exposure, which frequently includes lymphadenopathy, malaise, headaches, and muscle aches. A different diagnostic approach is available for monkeypox, including histopathological analysis, electron microscopy, immunoassays, polymerase chain reaction, genome sequencing, microarrays, loop-mediated isothermal amplification technology and CRISPR (i.e., "clustered regularly interspaced short palindromic repeats"). There are currently no particular, clinically effective treatments available for the monkeypox virus. An initial treatment is cidofovir. As a monophosphate nucleotide analog, cidofovir is transformed into an inhibitor of viral DNA polymerase by cellular kinases, which is analogous to cidofovir's function in inhibiting viral DNA synthesis. The European Medicine Agency and the Food and Drug Administration have both granted permission for IMVAMUNE, a replication-deficient, attenuated third-generation modified vaccinia Ankara vaccine, to be used for the prevention of smallpox and monkeypox in adults.

Impact of Monkeypox Virus Infection on Immune Parameters in a Woman With Human Immunodeficiency Virus Receiving Clinically Effective Antiretroviral Therapy

We describe the immunologic and virologic impact of monkeypox (mpox) infection in a woman with human immunodeficiency virus (HIV) whose plasma HIV viremia was suppressed by clinically effective antiretroviral therapy. Extensive phenotypic analyses of B and T cells in peripheral blood and biomarkers in plasma showed significant immunologic perturbations despite the presence of mild mpox disease. Dramatic shifts were noted in the frequencies of total B cells, plasmablasts, and plasmablast immunoglobulin isotypes. Flow cytometric analyses showed a dramatic increase in the frequency of CD38+HLA-DR+ CD8+ T cells after mpox infection. Our data offer guidance for future studies involving mpox infection in affected populations.

Effectiveness of Antiviral Drugs <em>versus</em> Vaccine against MPOX Virus Infection

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Atypical Clinical presentation of a patient with Monkeypox

Presentation The Monkeypox virus is spreading in the European continent. A 36-year-old Irish man presented with a cellulitis lesion on the nose, spreading to the cheeks and upper lip. Atypical clinical features of the evolving outbreak are posing a community and healthcare risk to its management. Diagnosis Real-time PCR assay of the lesion swab revealed Monkeypox virus. The biochemical and hematological blood indices were normal, except for C-Reactive Protein, which was higher than normal. Treatment The patient was put on 750 mg intravenous Acyclovir, 15mg/kg twice a day of Vancomycin and 2g/day Ceftriaxone infusion. Discussion Cellulitis lesions are an atypical clinical feature of Monkeypox virus infection. Its management, using antibiotics and antiviral drugs, treated the infection and confined the spread of the virus around the patient's nose.

Monkeypox-Associated Disciform Keratitis

PURPOSE

The purpose of this study was to describe a case of monkeypox (MPX)-associated disciform keratitis.

METHODS

This is a case report.

RESULTS

A 36-year-old male patient presented to the infectious diseases clinic with a 1-week history of disseminated pustular skin lesions, a 4-day history of constitutional symptoms, and redness in the left eye. Testing of blood, 2 skin lesions, and a conjunctival swab confirmed the presence of MPX virus by polymerase chain reaction. On ophthalmologic examination on the 17th day of illness, there was a corneal epithelial ridge that stained with fluorescein with disciform corneal edema and underlying keratic precipitates. The patient was treated with oral tecovirimat 600 mg twice a day for 14 days and topical prednisolone acetate 1% 4 times daily, starting 2 days later. On completion of oral treatment, his corneal findings had resolved except for a small subepithelial scar at which time topical steroids were tapered.

CONCLUSIONS

MPX may cause disciform keratitis and scarring that closely resembles other ocular viral infections. Clinical trials are urgently needed to define the optimal management of human MPX infections and reduce vision loss.

Mpox (monkeypox): Diagnosis, prevention, and management in adults

ABSTRACT

Mpox (formerly "monkeypox") is a viral zoonosis that presents similarly to smallpox but is less contagious and causes less severe disease. Mpox may be transmitted from infected animals to humans through direct contact or a scratch or bite. Human-to-human transmission occurs through direct contact, respiratory droplets, and fomites. Two vaccines, JYNNEOS® and ACAM2000®, are currently available for postexposure prophylaxis as well as for prevention in certain populations at high risk for mpox. Most cases of mpox are self-limited; however, tecovirimat, brincidofovir, and cidofovir are available as treatments for at-risk populations.

Diabetes mellitus: Lessons from COVID-19 for monkeypox infection

BACKGROUND AND AIMS

Type 2 Diabetes Mellitus is known to be linked to malfunctioning antiviral defense; however, its association with the severity of monkeypox is poorly understood. In this review, we discuss key immunological mechanisms in the antiviral response affected by poor glucose control that could impact the susceptibility and severity of monkeypox infection, leading to a heightened emphasis on the use of the available antidiabetic drugs.

METHODS

We searched PubMed and Google scholar for articles published from January 1985 to August 2022. No criteria for publication data were set, and all articles in English were included.

RESULTS

Currently, there are no studies about the risk or consequences of monkeypox infection in the diabetic population. A high incidence of diabetes is reported in countries such as China, India, Pakistan, EUA, Indonesia, Brazil, Mexico, Bangladesh, Japan, and Egypt, where unfortunately imported cases of monkeypox have been reported and the infection continues to spread.

CONCLUSIONS

High incidence of diabetes together with the cessation of smallpox vaccination has left large numbers of the human population unprotected against monkeypox. The best option for the population remains confined to the prevention of infection as well as the use of hypoglycemic agents that have also been shown to improve immune mechanisms associated with viral protection.

[Monkeypox: proposals for care in pregnancy]

Although the 2022 Monkeypox virus epidemic mostly affects males, particularly men having sex with men, transmission to women may also occur. In case of MPXV infection in pregnancy, transmission to the fetus can result in very severe disease. Thus, caregivers should be aware of the measures to be taken according to the available evidence, in case of exposure or in case of symptoms particularly skin rash compatible with this diagnosis in a pregnant woman. Pregnant women should have access to vaccination, vaccinia immunoglobulin or antiviral medications as required.

Outbreak of Monkeypox Virus Disease: An Update on Epidemiology, Pathophysiology and Available Treatment Options

The monkeypox virus is a zoonotic illness with a tropical distribution in Africa, and around the world. The disease is spread through contact with infected animals or humans, and can also be spread from person to person through close contact with respiratory or bodily fluids. Fever, swollen lymph nodes, blisters, and crusted rashes characterize the disease. The incubation period is five to twenty-one days. It is difficult to distinguish the rash caused by infection from varicella and smallpox. Laboratory investigations are essential aspects of illness diagnosis and surveillance, and novel tests are required for more accurate and faster diagnosis. Antiviral drugs are being used to treat monkeypox. Scarring as well as other comorbidities, are prevalent in survivors, with the case mortality rate varying from 1 to 11%. The virus was found in monkeys at a Danish research facility in 1958, from which the term 'monkeypox' is derived. The primary human case was found in a child in the Democratic Republic of the Congo (DRC) in 1970. The World Health Organisation (WHO) has recently declared monkeypox a public health emergency of international concern. This manuscript attempts to review the various aspects of monkeypox disease and its allopathic as well as alternative treatment options available and serves as a valuable resource for healthcare professionals, researchers, and the general public.

Recent Advances in the Prevention and Management of Monkeypox Viral Infection in Humans

BACKGROUND

There have been several neglected infectious pathogens that have reemerged in the last few decades, including the monkeypox virus, a virus from the orthopoxviral genus that causes monkeypox and is transmitted between animals and humans. The human monkeypox outbreak has spread to several different countries. Because of the outbreak's unusually high case count and lack of connections to endemic nations, there are concerns that the monkeypox transmission pattern may have changed.

OBJECTIVE

The current study aimed to provide recent advancements in the prevention and management of the monkeypox virus in humans.

METHODOLOGY

We have highlighted recent advancements in the prevention and management of the monkeypox virus in humans in this work.

RESULTS

For the treatment and prevention of monkeypox, new medications and vaccinations are being used, and more study is needed to understand the epidemiology, biology, and ecology of the virus in endemic regions and stop future global outbreaks. Vaccines available in the market for the treatment of viruses are JYNEOS and ACAM2000. Some of the antiviral drugs, such as tecovirimat, brincidofovir, cidofovir, trifluridine, and vaccinia immune globulin, are used for the treatment of the monkeypox virus. Some of the vaccines, such as NIOCH-14, Cidofovir, CMX-001, and ST-246, are currently in clinical trials.

CONCLUSION

We have, herein, covered features of monkeypox viral biology that are important for risk assessment and getting ready for an outbreak of the monkeypox virus, with a focus on recent advances in knowledge of the virus's host range, evolutionary potential, and potential targets for neutralization.

New Perspectives on Antimicrobial Agents: Tecovirimat for Treatment of Human Monkeypox Virus

Tecovirimat is an antiviral drug initially developed against variola virus (VARV) to treat smallpox infection. Due to its mechanism of action, it has activity against the family of orthopoxviruses, including vaccinia and the human monkeypox virus (HMPXV). Efficacy studies have thus far been limited to animal models, with human safety trials showing no serious adverse events. Currently approved by the FDA only for the treatment of smallpox, tecovirimat shows promise for the treatment of HMPXV. Tecovirimat has been prescribed via an expanded access for an investigational new drug protocol during the 2022 outbreak. This review will examine the literature surrounding tecovirimat's mechanism of action, pharmacokinetics, safety, efficacy, and potential for resistance.

A severe monkeypox infection in a patient with an advanced HIV infection treated with tecovirimat: clinical and virological outcome

A patient aged 28 years who is immunocompromised and living with HIV/AIDS became infected with the monkeypox virus (MPXV). His clinical condition deteriorated for 37 days, with fever, skin lesions, and diarrhea before going to the infectious diseases department, where his severe, protracted infection was treated with tecovirimat for 14 days. His condition rapidly improved, and the skin lesions decreased, as did the MPXV loads, with no adverse events. This case indicates that tecovirimat might be effective for treating patients who are immunocompromised and are infected with MPXV.

Cidofovir for treating complicated monkeypox in a man with acquired immune deficiency syndrome

In July 23, the World Health Organization (WHO) declared monkeypox (MPX) a global health emergency of international concern given its rapid spread. So far, most current MPX outbreaks have involved young men who have sex with men (MSM), although with overall mild, self-limiting clinical manifestations. We aim to describe the case of an HIV positive young MSM whose status of immune compromission probably contributed to a more severe clinical course of MPX disease, thus requiring hospitalization and antiviral treatment. He was effectively treated with Cidofovir that may be considered as a valuable component of a multi-faceted management of severe MPX.

Compassionate Use of Tecovirimat for the Treatment of Monkeypox Infection

This case series describes the clinical resolution of systemic symptoms and lesions, along with any adverse events, in patients with monkeypox infection who were treated with tecovirimat on a compassionate use basis.

Monkeypox diagnostic and treatment capacity at epidemic onset: A VACCELERATE online survey

We approached European tertiary care institutions to provide details regarding their management of the current human monkeypox outbreak. 73 out of 105 sites stated to have capacities to manage the outbreak adequately amid the ongoing coronavirus disease 2019 pandemic. There are effective protective measures to prevent nosocomial infections in place at nearly all institutions. Diagnostic and treatment capacities on the other hand have potential to be improved.

Approaching monkeypox: a guide for clinicians

The 2022 outbreak of monkeypox virus infection has expanded far beyond regions in which the disease was previously endemic. Monkeypox has a wide range of manifestations, some of which are unique to this outbreak. Novel clinical presentations, testing limitations, and a lack of available treatments have contributed to delays in recognition, diagnosis, and treatment of monkeypox. As health care workers and governments fight this rare viral infection, which may become a routine diagnosis, early recognition of potential signs and symptoms along with appropriate testing is essential to prevent continuing spread and potential endemicity.

In Silico Repurposed Drugs against Monkeypox Virus

Monkeypox is an emerging epidemic of concern. The disease is caused by the monkeypox virus and an increasing global incidence with a 2022 outbreak that has spread to Europe amid the COVID-19 pandemic. The new outbreak is associated with novel, previously undiscovered mutations and variants. Currently, the US Food and Drug Administration (FDA) approved poxvirus treatment involves the use of tecovirimat. However, there is otherwise limited pharmacopoeia and research interest in monkeypox. In this study, virtual screening and molecular dynamics were employed to explore the potential repurposing of multiple drugs previously approved by the FDA or other jurisdictions for other applications. Several drugs are predicted to tightly bind to viral proteins, which are crucial in viral replication, including molecules which show high potential for binding the monkeypox D13L capsid protein, whose inhibition has previously been demonstrated to suppress viral replication.

Relooking the monkeypox virus during this present outbreak: epidemiology to therapeutics and vaccines

OBJECTIVE

The recent monkeypox disease outbreak is another significant threat during the ongoing COVID-19 pandemic. This viral disease is zoonotic and contagious. The viral disease outbreak is considered the substantial infection possessed by the Orthopoxvirus family species after the smallpox virus' obliteration, a representative of the same family. It has potentially threatened the Republic of Congo's regions and certain African subcontinent zones. Although repeated outbreaks have been reported in several parts of the world, as conferred from the epidemiological data, very little is explored about the disease landscape. Thus, here we have reviewed the current status of the monkeypox virus along with therapeutic options available to humanity.

MATERIALS AND METHODS

We have accessed and reviewed the available literature on the monkeypox virus to highlight its epidemiology, pathogenicity, virulence, and therapeutic options available. For the review, we have searched different literature and database such as PubMed, PubMed Central, Google Scholar, Web of Science, Scopus, etc., using different keywords such as "monkeypox", "Orthopox", "smallpox", "recent monkeypox outbreak", "therapeutic strategies", "monkeypox vaccines", etc. This review has included most of the significant references from 1983 to 2022.

RESULTS

It has been reported that the monkeypox virus shows a remarkable similarity with smallpox during the ongoing outbreak. Sometimes, it creates considerable confusion due to misdiagnosis and similarity with smallpox. The misdiagnosis of the disease should be immediately corrected by rendering some cutting-edge techniques especially intended to isolate the monkeypox virus. The pathophysiology and the histopathological data imply the immediate need to design effective therapeutics to confer resistance against the monkeypox virus. Most importantly, the potential implications of the disease are not given importance due to the lack of awareness programs. Moreover, specific evolutionary evidence is crucial for designing effective therapeutic strategies that confer high resistance, particularly against this species.

CONCLUSIONS

The review focuses on a brief overview of the recent monkeypox virus outbreak, infection biology, epidemiology, transmission, clinical symptoms, and therapeutic aspects. Such an attempt will support researchers, policymakers, and healthcare professionals for better treatment and containment of the infection caused by the monkeypox virus.