In a recent case report published on the Research Square * prepress server, the researchers described the symptoms and clinical manifestations of monkeypox infections between two Israeli patients.
Study: smallpox infection in a developed country: a case report. Image credit: Berkay Ataseven / Shutterstock
About the case report
The authors of this report described monkeypox infections between two Israeli men between the ages of 30 and 40 who had sex with men (MSM). Neither patient was vaccinated against smallpox and neither received antiviral therapy for smallpox.
Case 1
The patient had a normal body weight [indicated by body mass index (BMI) values], and the history of hemorrhoids and warts accumulated a year before the current monkeypox infection, and he had received vaccination against the human papilloma virus (HPV). The final HPV vaccine was given one month before the current infection. In addition, he had been infected with severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2) once despite having been vaccinated twice during the same year before the diagnosis of coronavirus disease 2019 (COVID-19).
On day 1, the patient reported a feeling of altered perianal skin texture with no visible skin lesions. On day 2, mild fever (37.5 ° C), fatigue, and muscle aches were reported. He had unprotected sex with his male partner until a day before the onset of symptoms. The couple had confirmed smallpox infection a few days before patient 1 and had unprotected sex with a European traveler. After being diagnosed with monkeypox infection, the patient was quarantined. On day 3, he presented with an increase in body temperature (38 ° C), chills, severe headaches, and sensitive right and left inguinal lymph nodes.
In addition, painless, elevated, serous papules were reported in the anal region and perianal region. Infection was suspected by the smallpox of the monkey, so the patient was referred for emergency care. All vital signs except body temperature were within the reference range and no new injuries were reported. Nasopharyngeal swabs and anal swabs were obtained from the patient for polymerase chain reaction (PCR) analysis, based on the patient’s diagnosis of monkeypox infection.
Laboratory tests were performed, including biochemical parameters such as liver function tests, electrolytes and creatinine, and complete blood count. The patient had a slight increase in neutrophil count (6 10e3 / µL), elevated levels of C-reactive protein (93.4 mg / L) and alanine transaminase (64 U / L) and was discharged from hospital. with prescription of prescribed and advised topical antibiotics. for panel testing of sexually transmitted diseases.
On day 4 of monkeypox infection, 10 pruritic pustular lesions were identified with an additional solitary papule at the buccal commissure. On day 5, the patient presented with lymphadenopathy, intense pain in the inguinal region, with additional injuries to the buttocks, anal region, and perianal region with umbilicus in the center. In addition, elevated erythematous spots were also detected on the limbs, trunk, and neck. He was prescribed creams for topical application, antihistamines and analgesics.
On day 6, the red spots transformed into umbilical, painless papules restricted to the upper extremities and trunk. On day 7, the patient presented with itchy bladder lesions in the anal region with severe dyskinesia and pain, so he sought urgent attention again. Laboratory test reports were similar to previous reports and the patient was discharged with medication comprising paracetamol and oxycodone. On the eighth day of infection, body temperature returned to normal, pain and lymphadenopathy decreased, and a crust of lesions was observed in the anal and perianal areas with persistent pruritus. The patient was very anxious about the rapid clinical alterations and the uncertain duration of the infection.
Case 2
A male patient suffering from human immunodeficiency virus (HIV) suffered from acquired immunodeficiency syndrome (AIDS), treated with a combination therapy that includes dolutegravir, lamivudine, and abacavir, and a CD4 + T lymphocyte count> 500 lymphocytes. / mm3 is suspected of being infected with the smallpox of the monkey. He also received medication with apixaban after a venous thromboembolism event.
The patient’s BMI was normal, he had a history of acuminate condyloma, and he had received the HPV vaccination, the final dose of which was received several weeks before the current infection. He initially presented with dysuria, general malaise, itching in the penis region, and enlarged unilateral inguinal lymph nodes. The onset of symptoms was reported 14 days after having unprotected sex with a European traveler.
On day 3, a solitary lesion with umbilicus was detected in the center of the penis and 10 lesions were detected the next day. Two days later, the patient presented with enlarged cervical ganglia and 10 pustular lesions of the penis with papules extending to non-genital regions of the body, although vital reports, urine analysis, and biochemistry testing were normal. .
On day 8, penile lesions appeared to be vesicular, and body papules were more numerous throughout the body; however, the face was saved. On the tenth day of infection, bark lesions were observed and some lesions disappeared three days later. Although the patient showed symptomatic improvement, the diagnosis of monkeypox infection made him anxious.
Conclusion
The authors believe that no case report before the present describes the clinical presentation of monkeypox infections in Israel and is also among the initial reports of infection among developed nations. Both cases presented atypical clinical presentations with asynchronous lesions in the trunk, limbs, genital, and anal regions; however, clinical presentations were similar to those of sporadic cases observed in Australia and Italy.
The report highlights the need to lower the threshold for suspicion of monkeypox infections and increase awareness and testing for monkeypox infections. In addition, health measures should be developed to minimize the transmission of monkeypox virus, but also to address the anxiety and stress of gay men.
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