1. Clinical evidence, high viral loads, and participant histories suggest that close contact is the primary mode of monkeypox transmission in this current outbreak.
2. Complications of monkeypox include proctitis and tonsillitis in those who have anal and oral sex, respectively.
Level of evidence assessment: 2 (good)
Summary of the study: Monkeypox was recently declared a public health emergency by the World Health Organization (WHO). This study aimed to characterize the clinical presentation and virological evaluation of confirmed cases of monkeypox in Spain. People with laboratory-confirmed monkeypox were recruited. Participants were mostly (92%) men who identified as gay, bisexual or other men who have sex with men (MSM). All participants presented with skin lesions, including genital, perianal and oral lesions. A large percentage of participants reported systemic symptoms, such as flu-like illness. Complications included proctitis, with most cases reporting prior anal-receptive intercourse, and tonsillitis, with most cases reporting prior oral-receptive intercourse. Interestingly, smallpox vaccination was reported in 18% of participants, which may warrant further investigation into the effectiveness of the vaccine against monkeypox infection. Limitations of this study include the inability to report an accurate incubation period due to multiple exposure events reported by participants. Nevertheless, this study adds to the current evidence for a method of transmission and clinical presentation of monkeypox during the current epidemic.
In-Depth [prospective cohort study]: This multicenter prospective cohort study recruited participants from three hospitals in Spain. Eligibility criteria included monkeypox infection confirmed by laboratory testing of a skin lesion, anal or oropharyngeal swab. Participants were interviewed by a dermatologist or a specialist in sexually transmitted infections. The results included a report of the qualitative characteristics of the participants as well as clinical results 14 days after the initial presentation. A total of 181 patients were included in the study, 175 (97%) were male and the mean age was 37.0 years. 166 (92%) participants identified as gay, bisexual and other men who have sex with men (MSM). 72 (40%) of the participants were HIV-positive, of whom 71 (99%) were on antiretroviral treatment. 32 (18%) people reported having received a smallpox vaccine. All participants had skin lesions and 99% of skin lesion swabs tested positive. Common locations of skin lesions included anogenital regions (78%), hands and feet (60%), trunk and extremities (57%), and oral and perioral regions (43%).
Three patients required hospitalization and no deaths were reported. 160 (88%) participants reported systemic symptoms, such as flu-like illness. Complications observed included proctitis (25%), tonsillitis (10%) and penile edema (8%). MSM who had receptive anal intercourse had more frequent proctitis (absolute difference 31% [95% CI 19-44]; p
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