Open access peer-reviewed chapter - ONLINE FIRST
Abstract
Cases of Monkeypox virus infection (Mpox) were initially relegated to Central and West Africa; however, in May 2022, outbreaks began to occur in non-endemic areas. Patients with Mpox infection can present with several symptoms in the gastrointestinal tract, such as abdominal pain, proctitis, and hematochezia. While several case reports have been published that show the presentation and management of patients with M. pox, it is fundamentally essential to have a collective resource for gastroenterologists to identify patients with this infection and appropriately manage them to ensure a safe outcome. The purpose of this book chapter is to present the variety of gastrointestinal manifestations that can present in patients infected with Mpox and the best way to manage them appropriately. We will present the current state of knowledge about gastrointestinal manifestations of Mpox by analyzing key studies that have been published to date and provide a broad overview of the subject as it pertains to gastroenterologists.
Keywords
- Mpox
- monkey pox
- abdominal pain
- proctitis
- hematochezia
- rectal pain
- tenesmus
- gastrointestinal symptoms
1. Introduction
Monkeypox virus (Mpox) is a zoonotic pathogen that belongs to the Orthopoxvirus genus of the Poxviridae family. It was first isolated and identified in 1958 during an outbreak in monkeys from Singapore in a laboratory in Denmark. The first human case of monkeypox was identified in the Democratic Republic of Congo in 1970. Mpox is divided into two distinct clades, based on where it is endemic: the Congo Basin (Central African) and the West African clade. The Congo Basin clade is associated with more severe diseases with higher mortality rates (10%) than the West African clade (4%). The increase in monkeypox cases outside these endemic regions highlights the need for improved surveillance and response strategies. The fact that most cases of Mpox occur in rural Africa means that there is significant underreporting of infections with this pathogen, and thus a considerable underestimation of its potential threat to the global population [1, 2].
The monkeypox virus is believed to be derived from other orthopoxviruses, particularly the variola virus, which is the causative agent of smallpox, as well as the cowpox virus. The virus itself is relatively large (200–250 nm), brick-shaped, and surrounded by a lipoprotein envelope with a linear double-stranded DNA genome. It relies on host ribosomes for mRNA translation but retains all other necessary proteins for transcription and replication. The primary reservoir hosts are thought to be rodents. The African giant pouched rat, as well as some other various species of squirrels, have been implicated as potential hosts. Increasing genetic diversity and variability of the monkeypox virus raises concerns regarding its ability to adapt to new hosts and environments, as well as creating more challenges for public health strategies and the development of vaccines. Zoonotic transmission is classically regarded as the primary route through which humans were initially infected, which typically occurs through direct contact with infected animals or exposure to their bodily fluids. This usually occurs through bites, scratches, or consumption of bushmeat. Human-to-human transmission of the monkeypox virus can occur but was typically considered less common. Interestingly, the Congo Basin clade of Mpox has several documented cases of human-to-human transmission compared to the West African clade. The difference in virulence between these two clades can be attributed to variability in genome organization. It was during the 2003 Mpox outbreak in the United States that Mpox received attention as a global public health threat. This was due to a multistate outbreak attributed to close contact with infected prairie dogs acquired as pets, with molecular investigations identifying the West African Clade as a causative source [2, 3, 4].
Human-to-human transmission can occur through respiratory droplets, direct contact with lesions on a person infected with Mpox, or through fomites, such as contaminated clothing or bedding. Some studies have shown that bodily fluids, such as semen, saliva, urine, and feces, can have very high viral loads. This suggests that sexual transmission is a major factor in the spread of the monkeypox virus. There is a concern that although human-to-human transmission has been limited in the past, the decreasing herd immunity to orthopoxviruses over time has led to the increasing spread of disease between humans. Behaviors such as increased contact with wildlife and bushmeat consumption have strongly contributed to recent monkeypox outbreaks. Other factors include international travel and the exotic pet trade market. Over the past several decades, sporadic cases have occurred with transmission between people traveling from Nigeria to places such as Israel, Singapore, the UK, Canada, and several US states, including Texas and Maryland. The most significant outbreak outside endemic areas of monkeypox occurred in 2022, with many cases reported in multiple countries, such as the United States, Canada, the United Kingdom, and several other European nations. This Mpox outbreak was declared a global health emergency because of the widespread prevalence of cases [2, 5].
With the observation of these outbreaks, it has become apparent that specific demographic populations are more vulnerable to infections. Men who have sex with men (MSM) are among the most vulnerable groups. Correlating factors and other vulnerable populations include HIV status and people who have not been vaccinated against smallpox, along with any individual with comorbidities that predispose them to weakened immune system responses. Since the discontinuation of routine smallpox vaccination in the 1970s, the apparent prevalence and incidence of Mpox infections have increased, revealing cross-immunity against Mpox. Studies from almost 600 confirmed cases in Spain in 2022 revealed that 99% of the cases affected MSM. Over 1300 cases were reported in Germany by mid-2022, mainly in the MSM population. Emerging data indicate that these recent outbreaks could be caused by the West African clade of Mpox, while other data suggests that a newly emerging clade could be the culprit. As of January 2023, there were a total of 84,716 confirmed cases [1, 2, 4, 5].
In general, the initial symptoms of infection with monkeypox virus include fever, headache, myalgia, lymphadenopathy, and rash development. Importantly, lymphadenopathy is a key feature of monkeypox infection that can differentiate it from smallpox infection. These symptoms usually follow an incubation period of 7–14 days, with an observed upper limit of approximately 21 days. Most infected patients are contagious during the several days of prodromal symptoms following the incubation period. The rash progresses through several stages (macular, papular, vesicular, and pustular) over 2–4 weeks and ultimately scabs over in most cases. Antibodies are typically detected in the serum when a rash begins to appear. After the rash has scabbed over and the crust has fallen off, patients are no longer considered contagious [2, 5].
In severe cases or those cases involving the vulnerable populations described above, more debilitating manifestations of the disease and complications can arise. In the MSM population, lesions predominantly affect the genital, perineal, and perianal areas. Inguinal lymphadenopathy is another predominant feature suggesting that sexual transmission plays a key role in the spread of Mpox. Patients can also present with several symptoms along the gastrointestinal tract, such as abdominal pain, proctitis, and hematochezia, which will be discussed in greater detail later in this chapter. The differential diagnoses of patients who present with the above symptoms should include smallpox, disseminated zoster, chickenpox, disseminated herpes simplex, measles, syphilis, scabies, rickettsial pox, bacterial skin infections, and drug-associated eruptions. Documented complications of Mpox infection include severe dehydration, sepsis, pneumonia, encephalitis, bacterial superinfection of the skin, permanent skin scarring, permanent corneal scarring, and death [5, 6].
In this chapter, we will present pertinent information about the gastrointestinal manifestations of Mpox covering diagnosis, symptomatology in the gastrointestinal tract, imaging and endoscopy findings, endoscopic precautions, as well as prevention and treatment measures currently in place, using the latest guidelines as well as evidence from case reports, case series, systematic reviews and meta-analysis that have been published in the global literature. Our aim is to serve as a resource for the healthcare team involved in patient management, particularly in the gastroenterology field of medicine.
2. Workup for the Mpox patient
When a patient with suspected Mpox presents in a clinical environment, the differential is broad. Establishing an assessment with a thorough history is key. When completing a physical examination for patients suspected of Mpox, wearing appropriate protective equipment, as outlined in the endoscopy section, is recommended. This ensures protection for both patients and hospital staff. The Centers for Disease Control (CDC) provides guidelines for endoscopy suite precautions and disposal of materials after exposure. A general skin exam can show lesions from the mouth to the anus (oral, perioral, perianal, perirectal, and genital lesions). A study by Thornhill et al. showed that 95% of the patients in the study had skin findings [7]. It is also essential to perform head, eye, neck, cardiac, respiratory, and abdominal assessments. A digital rectal examination may be indicated to appropriately assess for bleeding and rectal lesions when gastrointestinal complaints are voiced; however, this procedure may not be tolerated secondary to pain.
The standard workup for patients should include blood tests and imaging studies. Labs should be tailored according to the patient’s presentation. Initial labs can include but are not limited to a comprehensive metabolic panel (CMP), complete blood count (CBC), blood cultures, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), human immunodeficiency virus (HIV), hepatitis panel, rapid plasma reagin (RPR), and Chlamydia/Gonorrhea. When lesions are found, direct swab of the lesions is necessary to confirm the diagnosis. Unroofing the lesions is difficult to do with a swab, given that the lesions are filled with solid material. The use of sharps for unroofing is not recommended because of the risk of infection. The diagnostic test is a polymerase chain reaction of Orthopoxvirus DNA, and two swabs are recommended for each swabbed lesion [8].
Imaging can be used to further assess clinical and laboratory findings. Rectal magnetic resonance imaging (MRI) is recommended for patients presenting with proctitis, especially in cases of rectal perforation and/or obstruction. Abdominal imaging can also be performed using CT or MRI [9].
3. Gastrointestinal symptoms of Mpox
There is a cluster of gastrointestinal symptoms that are present in patients who present with Mpox, as shared in the introduction. Although there is evidence that the most common manifestations of Mpox are skin lesions, several large studies have reported the presence of gastrointestinal manifestations in both upper and lower tracts. We have summarized some pertinent GI findings in the studies listed below.
A systematic review by Ramakrishnan et al. examined several papers and patient profiles across multiple countries. The symptoms included abdominal pain, diarrhea, nausea, painful defecation, proctitis/rectitis (inflammation of the anus or rectal lining), proctalgia (sudden, severe, and episodic anorectal pain due to the potential involvement of anal sphincter spasms), rectal bleeding, rectal/anal pain, rectal perforation, tenesmus (painful and constant urge to defecate despite an empty colon or recent bowel movement), and vomiting. The authors determined that proctitis was the primary gastrointestinal manifestation of Mpox [10].
Thornhill et al. and presented an international case series of 528 patients with Mpox across 16 countries, highlighting the dermatologic and systemic findings. GI symptoms include anorectal pain, proctitis, tenesmus, diarrhea, pharyngitis, and odynophagia. The most common presenting symptoms were rash and skin lesions (95% of patients), pharyngitis (21% of patients), and proctitis/anorectal pain (14% of patients). A total of 97% of the patients had a positive PCR result obtained from the skin/anogenital area. Most encounters were conducted in an outpatient setting. Six% of patients were Hepatitis C antibody-positive and 2% were hepatitis C Virus RNA positive. The three most common places where patients presented in this study were HIV clinics, sexual health clinics, and the emergency department [7].
Liu et al. published a systematic review and meta-analysis by using 77 studies (4 cross-sectional studies that compared symptoms between HIV-infected and HIV-uninfected Mpox patients, and 13 case series with information on HIV status) which they included in the meta-analysis for comparing symptoms between HIV-infected and HIV-uninfected Mpox patients. Their meta-analysis showed that skin lesions, fever, and lymphadenopathy are the most commonly reported symptoms. Regarding GI symptoms, rectal pain/anal pain/proctitis was reported in 43 studies with a pooled estimated prevalence of 18.5%. Anogenital lesions were the most common type of skin lesions [11].
A cross-sectional study of patients was conducted between May 1 and July 1, 2022, 226 from 18 sites in 15 countries. Rashes or skin lesions were reported in 61% of the patients. A total of 55% reported genital or perianal lesions, 15% reported rectal pain, 6% reported diarrhea, and 4% reported both rectal pain and tenesmus. The authors commented that patients with HIV were more likely to have diarrhea or perianal rash. Nearly all patients in their study were MSM, half of whom had an HIV infection [12].
A systematic review and meta-analysis of gastrointestinal symptoms in Mpox patients was performed by analyzing a total of 31 studies with 9189 Mpox patients. The gastrointestinal symptoms were vomiting (15 studies), diarrhea (11 studies), nausea (10 studies), abdominal pain (nine studies), and anorexia (three studies). The overall pooled prevalence of abdominal pain (9%), anorexia (47%), diarrhea (5%), nausea (10%), and vomiting (12%). The overall pooled prevalence rates of oral ulcers, dysphagia, and odynophagia were 33%, 57%, and 31%, respectively [13].
Yakubovsky et al. reviewed the cases of 70 patients diagnosed with Mpox at the Tel Aviv Sourasky Medical Center. Their criteria for diagnosis of proctitis was meeting at least two of the following criteria: mucopurulent anal discharge, anorectal bleeding, anorectal pain, and anorectal itch, sensation of rectal fullness or incomplete defecation, and tenesmus. A total of 26 patients had signs and symptoms of proctitis. Three patients with proctitis had an anal mass protruding from the rectum accompanied by excruciating pain. Anal pain was the most common proctitis symptom, followed by anal discharge, and pain during defecation. Diarrhea, constipation, and bloody stools were seen in 4, 3, and 2 patients, respectively. Nineteen patients had anorectal lesions and 17 patients had proctitis symptoms preceding the rash [14].
Another study that performed rectal testing in 18 MSM with symptoms consistent with Mpox infection showed rectal Mpox DNA in 9/9 patients with proctitis and 7/9 patients without proctitis. 10/18 patients had HIV [15].
Hatami et al. published a systematic review and meta-analysis of Mpox-confirmed patients by analyzing peer-reviewed publications over the 10 years before and during the 2022 outbreak and their findings. Proctalgia/proctitis was an unprecedented clinical manifestation of Mpox during the 2022 outbreak, with a calculated pooled frequency of 16.6% [16].
A case report on the first two cases of monkeypox infection in humans diagnosed in Germany reported that one of the patients had dysphagia and white spots on the tonsils. Oral lesions appeared prior to the presence of other skin lesions [17].
This is particularly important for gastroenterologists, as they may be consulted to diagnose and treat symptoms of the upper gastrointestinal tract, such as dysphagia or odynophagia, or of the lower tract, such as proctitis. These findings can be helpful in terms of what is expected during endoscopy in patients who present with Mpox.
4. Pertinent history for the gastroenterologist
Obtaining the history of a patient, particularly if they have a history of sexually transmitted infections (STI) such as HIV/AIDS, is important, as several studies have shown this to be a coexisting infection. Pertinent information includes sexual orientation, HIV status, history of sexually transmitted infections (STI), and foreign travel. For male patients, it is also recommended to obtain a sexual history of MSM. The timing and onset of symptoms can also help to determine whether endoscopic intervention is necessary.
5. Imaging findings of Mpox
Few case reports have shown the imaging results of Mpox using CT or MRI. A case report of Mpox proctitis in a 61-year-old presenting with rectal pain and bleeding showed circumferential thickening of the low to mid-rectum with mesorectal fat stranding and lymphadenopathy on CT imaging [18]. Another report of a 41-year-old male presenting with rectal pain and facial rash showed a CT scan that revealed severe anorectal proctitis with discrete large mural hypoattenuated anorectal ulcers, perirectal fat stranding, pelvic free fluid, and an increased number of small inguinal lymph nodes [9]. A patient in his late 40s who had symptoms of rectal pain in addition to other symptoms underwent MRI of the rectum, which showed active proctitis with enlarged mesorectal space lymph nodes and inflammation of the lower anal canal mucosa at the anal verge [19]. A patient who presented with Mpox in his mid 40s with symptoms of fever, rash and rectal pain underwent MRI performed 5 days after admission, which showed inflammation affecting the mid-to-lower rectum with mural thickening, surrounding edema, and extensive reactive nodal changes within the mesorectum [20]. A retrospective study of 21 patients with PCR-positive Mpox who underwent abdominopelvic CT showed varying degrees of rectal thickening, with 17 of 21 patients having abnormal perirectal lymph nodes, and 20 out of 21 showing perirectal stranding (Figure 1) [21].
Figure 1.
Cross-sectional CT imaging of a 22-year-old male patient with Mpox. Circled areas highlight adenopathy [22].
Despite the limited availability of an imaging database, there are a few commonalities in the imaging findings among these patients. These characteristics seen on either CT or MRI include mesorectal fat stranding, lymphadenopathy, presence of ulcers, tract inflammation, and rectal wall thickening. Including these imaging findings in the differential diagnosis can aid in the correct diagnosis of the disease, particularly in patients presenting with proctitis or rectal pain.
6. Endoscopy findings of Mpox
Most publications in current literature provide symptomatic descriptions of Mpox presentations. Few studies have reported endoscopic findings in patients with Mpox. There are a few case reports of upper endoscopy and flexible sigmoidoscopy in the current literature.
Fernandez and Regino reported the case of a patient presenting with skin lesions, fever, sore throat, and severe dysphagia. Upper endoscopy showed ulcerated lesions in the oral cavity and hypopharynx and well-defined ulcers [23].
A case report from Germany analyzed six patients who self-identified as MSM with confirmed Mpox. The chief complaint of most patients was intense anal pain. Three patients underwent proctoscopy, which showed findings such as rectal ulcers, proctitis, and anal ulcers [24].
Another case report by Mavilla et al. examined a patient with Mpox-associated proctitis. The presenting complaint of the 34-year-old male patient with HIV was rectal pain and bleeding. Flexible sigmoidoscopy with biopsy revealed erosions in the distal sigmoid colon and severe proctitis, characterized by deep ulceration and scattered pustular lesions. Rectal biopsies were notable for ulcerated mucosa with viral cytopathic effects [25].
A case report of a 39-year-old HIV-positive male who presented with anal pain, dyspnea, and gastrointestinal bleeding for a 2-week duration showed colonoscopy findings notable for a 3-cm circumferential rectal ulcer with exudate, significant induration, and necrosis. Rectal biopsy revealed ulcerated mucosa with acute proctitis and necrosis. Mpox infection was confirmed using an anti-vaccine virus antibody [26].
An observational study of anal monkey pox disease, which included 65 men with monkeypox anal infection in a single proctology center who underwent anoscopy or rectoscopy performed during the first visit, showed perianal vesicles (n = 24 patients; 36.9%) and ulcerations in the perineal (n = 42; 64.6%), anal canal (n = 28; 43.0%), and rectal (n = 25; 38.4%) localizations. Proctitis was observed in 49 (75.4%) patients [27].
A UK-born male with HIV, aged in his 30s, presented with a 2-day history of rectal pain. Proctoscopy revealed erythematous rectal mucosa with evidence of blood and pus in rectal swabs [19].
Our team in Tennessee performed flexible sigmoidoscopy in a patient with Mpox, which revealed a non-bleeding rectal ulcer, friable rectum and anal canal, micro-abscesses in the rectum and anus, and a rectal polyp (Figure 2). Rectal polyp biopsy was notable for focal active proctitis with histio-lymphocytic aggregates and was negative for dysplasia. Anal canal biopsy was notable for colonic-type glandular mucosa with cryptitis, ulceration, granulation tissue, and reactive epithelial changes (Figure 3) [22].
Figure 2.
Cross-sectional CT imaging of Mpox patient indicating rectal wall thickening (red arrow) [22].
Figure 3.
Endoscopic findings in a patient diagnosed with Mpox. A. Arrows pointing to a rectal ulcer. B. Micro-abscesses seen in the rectum and anus. C. Rectal polyp [22].
Most of the published findings on endoscopy are from the lower GI tract (flexible sigmoidoscopy or colonoscopy), likely because patients present with symptoms of proctitis, rectal pain, rectal bleeding, or tenesmus. Endoscopy findings are notable for proctitis, a unique presentation in the most recent outbreak, as well as mucosal ulceration and necrosis. Upper endoscopy revealed the presence of ulcers. If biopsies are obtained, they should be stained with antibodies specific for Mpox to improve diagnostic accuracy.
7. Management of Mpox
Treating patients with Mpox involves early recognition of the disease, institution of appropriate precautions, consultation with an infectious disease team, and the application of medical therapy.
7.1 Isolation precautions during hospitalization
Once a patient has been identified as having Mpox infection, they should be placed in an isolated room with their own bathroom. For any procedures involving the airway or endoscopy, it is recommended that they be performed in an airborne infection isolation room. Healthcare personnel should wear personal protective equipment (PPE), which includes gowns, gloves, eye protection, and respirators.
If patients are suspected to have Mpox infection, they should be placed in isolation until the infection is ruled out. Patients with confirmed infection should be placed in isolation until all lesions have crusted, crusts separated, and a fresh layer of healthy skin has formed underneath.
If a patient is exposed, they will need a 21-day monitoring period, which includes a daily skin exam. If patients present with other symptoms without a rash, the CDC recommends empirical isolation precautions for 5 days, which can extend beyond the original 21-day period [28].
7.2 Isolation precautions during hospitalization
Gastroenterologists can be exposed to patients with Mpox during clinical interactions and endoscopy. For clinical examinations that involve examination of the anorectal area, precautions should be taken, which should include ensuring that patients are placed in isolated rooms and PPE is donned appropriately. Proper sterilization of the endoscopy suite and precaution for reusing it to ensure adequate clearance of the virus, as well as sterilization of the equipment according to CDC guidelines, is recommended. As the virus can exist for days to weeks at room temperature outside the body, this must be taken into account before clearing a room prior to repeated use. Appropriate methods for cleaning exposed rooms include chemical disinfectants and ultraviolet (UV) irradiation [29].
7.3 Vaccines for prevention of Mpox
Vaccination is available for pre- and post-exposure prophylaxis. The vaccines available are the Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine and the ACAM2000 vaccine [30]. Given the self-limiting nature of infection in immunocompetent individuals, pre-exposure prophylaxis vaccination is reserved for persons with high behavioral or occupational risk factors. Pre-exposure prophylaxis is usually given with the MVA Vaccine. Two doses are given 4 weeks apart [31]. The MVA Vaccine is used over the ACAM2000 since it is associated with less adverse effects [32]. Vaccination can help reduce the risk of Mpox and help protect against severe symptoms if infection does develop.
Post-exposure prophylaxis is performed with the MVA Vaccine as well. Post-exposure vaccination is usually performed for high-risk exposures in either the community (sexual contact of mucous membranes or contact of mucous membrane with bodily fluids of individual with Mpox) or health care (contact of mucous membrane with bodily fluids of individual with Mpox) setting [33]. Post-exposure prophylaxis can be performed for intermediate-risk exposures on a case-by-case basis.
7.4 Treatment of Mpox
Tecovirimat (TPOXX, ST-246) is the first-line therapeutic option for Mpox treatment. Other additional therapeutics are Brincidofovir (CMX001 or Tembexa) and Vaccinia Immune Globulin (VIGIV) and Cidofovir (Vistide) for patients who need additions/alternative treatments [34].
Once a diagnosis of monkeypox is established, treatment should be tailored to the patient’s immunocompetence and presenting symptoms. If a patient is immunocompetent, the infection is relatively mild and usually clears without significant medical intervention. If pain is present in these patients, supportive care with pain control directed at the area causing pain should be performed, in addition to pain management with oral NSAIDS and/or acetaminophen. Stool softeners and lidocaine can be considered in immunocompetent patients with anorectal involvement [35].
For patients who are immunosuppressed, at risk for disseminated infection, pregnant, under the age of 18, and/or subject to a severe monkeypox infection, antiviral therapy is initiated. Tecovirimat, an orthopoxvirus protein inhibitor, is the antiviral agent of choice. Although Tecovirimat is well-tolerated and has been shown to have survival benefits in animal models, studies are still being performed to assess its full efficacy in humans with active disease. Treatment usually lasts for 14 days but can be longer [34, 36, 37].
To assist with the assessment of the patient and initiation of appropriate antiviral treatment, infectious disease team should be consulted early in the patient’s course. They should also work closely with gastroenterology physicians for diagnosis, treatment, and follow-up. Once treated, patients should be examined for any signs or symptoms of recurrent infection for at least 21 days. If no changes occur during that period, the patient may return to all activities of daily living without restriction. If patients develop worsening symptoms, they are to immediately contact the health department for the next steps. Patients should also frequently follow-up with gastroenterology, infectious diseases, and primary care providers.
8. Conclusion
The recent global outbreak of Mpox after the COVID-19 outbreak highlights the need to equip healthcare providers and patients with the right tools and treatment for prevention, early diagnosis, and treatment of patients infected with Mpox. A low threshold for Mpox should be placed in high-risk patients, particularly those patients who are MSM and HIV-positive. The most common physical exam finding is skin lesions with a characteristic appearance. Systemic symptoms such as fever and malaise are present. As the focus of this chapter is on gastrointestinal presentation of Mpox, there are several published reports on symptoms such as proctitis, rectal pain, and tenesmus. Patients with a history of Mpox should be placed in isolation according to the guidelines published by the CDC or guidelines per the hospital. Laboratory work and imaging, particularly of the abdomen and pelvis, can are useful diagnostic tools. If endoscopy is planned, appropriate staining should be performed to correctly diagnose Mpox. A multidisciplinary team should be engaged, which includes the infectious disease team, gastroenterologist, surgeon, and primary care provider, for post-discharge follow-up. Prophylactic and treatment medications are available for high-risk patients and those infected with Mpox, respectively.
While there are well-published case series and case studies describing various aspects of Mpox infection in various parts of the globe, it is necessary to have a uniform database to store information that can aid healthcare workers to identify the disease early and implementing data-proven treatment strategies. Few studies are available on endoscopy findings and CT/MRI results of patients with Mpox, which highlights the need to build a database that can aid healthcare providers in terms of what symptoms and findings are expected. A management algorithm for patients with Mpox will also aid in providing quality care by educating providers on evidence-based strategies to ensure better health outcomes.
Acknowledgments
The authors would like to thank all of our patients and acknowledge all of the staff at the Regional One Health Hospital in Memphis, TN as well as the University of Tennessee Health Science Center.
References
- 1.
Karagoz A, Tombuloglu H, Alsaeed M, Tombuloglu G, AlRubaish AA, Mahmoud A, et al. Monkeypox (mpox) virus: Classification, origin, transmission, genome organization, antiviral drugs, and molecular diagnosis. Journal of Infection and Public Health. 2023; 16 (4):531-541 - 2.
Moore M, Rathish B, Zahra F. MPox (Monkeypox). In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574519 [Accessed: October 10, 2024] - 3.
Petersen E, Kantele A, Koopmans M, Asogun D, Yinka-Ogunleye A, Ihekweazu C, et al. Human Monkeypox: Epidemiologic and clinical characteristics, diagnosis, and prevention. Infectious Disease Clinics of North America. 2019; 33 (4):1027-1043 - 4.
Huang Y, Mu L, Wang W. Monkeypox: Epidemiology, pathogenesis, treatment and prevention. Signal Transduction and Targeted Therapy. 2022; 7 (1):373 - 5.
Elsayed S, Bondy L, Hanage WP. Monkeypox virus infections in humans. Clinical Microbiology Reviews. 2022; 35 (4):e0009222 - 6.
Gessain A, Nakoune E, Yazdanpanah Y. Monkeypox. The New England Journal of Medicine. 2022; 387 (19):1783-1793 - 7.
Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al. Monkeypox virus infection in humans across 16 countries—April-June 2022. The New England Journal of Medicine. 2022; 387 (8):679-691 - 8.
CDC. Guidelines for Collecting and Handling Specimens for Mpox Testing. 2024. Available from: https://www.cdc.gov/mpox/hcp/diagnosis-testing/collecting-specimens.html [Accessed: October 10, 2024] - 9.
Messina MD, Wolf EL, Kanmaniraja D, Alpert PL, Ricci ZJ. Imaging features of anorectal proctitis in monkeypox infection. Clinical Imaging. 2022; 92 :109-111 - 10.
Ramakrishnan R, Shenoy A, Madhavan R, Meyer D. Mpox gastrointestinal manifestations: A systematic review. BMJ Open Gastroenterology. 2024; 11 (1):e001266 - 11.
Liu Q, Fu L, Wang B, Sun Y, Wu X, Peng X, et al. Clinical characteristics of human Mpox (Monkeypox) in 2022: A systematic review and meta-analysis. Pathogens. 2023; 12 (1):1-14 - 12.
Angelo KM, Smith T, Camprubí-Ferrer D, Balerdi-Sarasola L, Díaz Menéndez M, Servera-Negre G, et al. Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: A cross-sectional study. The Lancet Infectious Diseases. 2023; 23 (2):196-206 - 13.
Simadibrata DM, Lesmana E, Pratama MIA, Annisa NG, Thenedi K, Simadibrata M. Gastrointestinal symptoms of monkeypox infection: A systematic review and meta-analysis. Journal of Medical Virology. 2023; 95 (4):e28709 - 14.
Yakubovsky M, Shasha D, Reich S, Tau L, Friedel N, Halutz O, et al. Mpox presenting as proctitis in men who have sex with men. Clinical Infectious Diseases. 2023; 76 (3):528-530 - 15.
Meyerowitz EA, Gendlina I, Desai VJ, Grossberg R, Nair SR, Pujar B, et al. Anorectal testing for Mpox virus infection in men who have sex with men with and without proctitis. Clinical Infectious Diseases. 2023; 76 (5):934-937 - 16.
Hatami H, Jamshidi P, Arbabi M, Safavi-Naini SAA, Farokh P, Izadi-Jorshari G, et al. Demographic, epidemiologic, and clinical characteristics of human monkeypox disease pre- and post-2022 outbreaks: A systematic review and meta-analysis. Biomedicine. 2023; 11 (3):1-71 - 17.
Noe S, Zange S, Seilmaier M, Antwerpen MH, Fenzl T, Schneider J, et al. Clinical and virological features of first human monkeypox cases in Germany. Infection. 2023; 51 (1):265-270 - 18.
Kearns C, Orsi M, Sanchez CJ, Calle F. Mpox (monkeypox) proctitis. Radiographics. 2023; 43 (3):1-2 - 19.
Gedela K, Da Silva Fontoura D, Salam A, Gorman G, Golden J, O’Hara G, et al. Infectious proctitis due to human Mpox. Clinical Infectious Diseases. 2023; 76 (3):e1424-e1427 - 20.
Brown L, Delaney C, Hainsworth A. Monkeypox-associated proctitis and rectal wall perforation. BML Case Reports. 2023; 16 (1):1-5 - 21.
Ola D, Dane B, Shanbhogue K, Smereka P. Rectal and perirectal CT findings in patients with monkeypox virus infection. Abdominal Radiology (New York). 2023; 48 (7):2284-2291 - 22.
Jowhar D, Salcedo C, Verne GN. P0219 - Proctitis in a Patient with Mpox, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology - 23.
Fernandez HM, Regino WO. GI involvement in monkeypox. Gastrointestinal Endoscopy. 2023; 97 (6):1160-1161 - 24.
Pfäfflin F, Wendisch D, Scherer R, Jürgens L, Godzick-Njomgang G, Tranter E, et al. Monkeypox in-patients with severe anal pain. Infection. 2023; 51 (2):483-487 - 25.
Mavilia MG, Putra I, Song X, Cappa J. Endoscopic and histologic assessment of monkey pox-associated proctitis. Clinical Gastroenterology and Hepatology. 2023; 21 (1):A19 - 26.
Alhalaseh Y, Modi MB, Haddad S, Souchik A, Speiser JJ, Massarani-Wafai R, et al. Mpox case presenting with genital lesions and proctitis. The American Journal of Dermatopathology. 2024; 46 (4):243-246 - 27.
Le Vavasseur B, Bendaoud S, Taieb S, Heym B, Dahlouk SY, Leclerc EJ, et al. Anal monkeypox disease: Description of 65 cases. Diseases of the Colon and Rectum. 1 Feb 2024; 67 (2):280-285. DOI: 10.1097/DCR.0000000000002899. Epub 2023 Oct 23. PMID: 37878465 - 28.
CDC. Mpox Infection Prevention and Control in Healthcare Settings. 2024. Available from: https://www.cdc.gov/mpox/hcp/infection-control/healthcare-settings.html [Accessed: October 10, 2024] - 29.
Canakis A, Kim RE, Sinha P, Raufman JP. Addressing the risk of monkeypox exposure during gastrointestinal endoscopy. Annals of Gastroenterology. 2023; 36 (1):1-5 - 30.
United States Food and Drug Administration. Key Facts About Vaccines to Prevent Mpox Disease. 2024. Available from: https://www.fda.gov/vaccines-blood-biologics/vaccines/key-facts-about-vaccines-prevent-mpox-disease [Accessed: October 10, 2024] - 31.
Center for Disease Control. Interim Clinical Considerations for Use of Vaccine for Mpox Prevention in the United States. 2024. Available from: https://www.cdc.gov/mpox/hcp/vaccine-considerations/vaccination-overview.html [Accessed: October 10, 2024] - 32.
Center for Disease Control. Use of JYNNEOS (Smallpox and Monkeypox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occupational Exposure to Orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices—United States, 2022. Available from: https://www.cdc.gov/mmwr/volumes/71/wr/mm7122e1.htm [Accessed: October 10, 2024] - 33.
National Center for Emerging and Zoonotic Infectious Diseases (U.S.). Division of High-Consequence Pathogens and Pathology. Monkeypox: Monitoring People Who have been Exposed. 2022. Available from: https://stacks.cdc.gov/view/cdc/117868 [Accessed: October 10, 2024] - 34.
National Center for Emerging and Zoonotic Infectious Diseases (U.S.). Division of High-Consequence Pathogens and Pathology. Interim Clinical Guidance for the Treatment of Monkeypox. 2022. Available from: https://stacks.cdc.gov/view/cdc/118351 [Accessed: October 10, 2024] - 35.
CDC. Clinical Considerations for Pain Management. 2024. Available from: https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html [Accessed: October 10, 2024] - 36.
Centers for Disease Control and Prevention. Tecovirimat (TPOXX) for Treatment of Mpox. 2024. Available from: https://www.cdc.gov/mpox/hcp/clinical-care/tecovirimat.html [Accessed: October 10, 2024] - 37.
Yu PA, Elmor R, Muhammad K, Yu YC, Rao AK. Tecovirimat use under expanded access to treat Mpox in the United States, 2022-2023. NEJM Evidence. 2024; 3 (10):EVIDoa2400189