Monkeypox Infection With Primarily Mucosal Involvement.

ABSTRACT: Since May 2022, several nonendemic countries face a monkeypox outbreak, with clinic and epidemiological characteristics distinct from the classic ones. Primarily affecting the sexually active population, these cases present with mucocutaneous lesions mainly localized in perioral, genital, and anal areas. A retrospective study was conducted in a tertiary center in Lisbon, to characterize the population diagnosed with monkeypox infection with primarily mucosal involvement.

Ongoing monkeypox virus outbreak, Portugal, 29 April to 23 May 2022.

Up to 27 May 2022, Portugal has detected 96 confirmed cases of monkeypox. We describe 27 confirmed cases (median age: 33 years (range: 22-51); all males), with an earliest symptom onset date of 29 April. Almost all cases (n = 25) live in the Lisbon and Tagus Valley health region. Most cases were neither part of identified transmission chains, nor linked to travel or had contact with symptomatic persons or with animals, suggesting the possible previously undetected spread of monkeypox.

Transcontinental Dissemination of the L2b/D-Da Recombinant Chlamydia trachomatis Lymphogranuloma venereum (LGV) Strain: Need of Broad Multi-Country Molecular Surveillance.

Previously, we identified a Chlamydia trachomatis lymphogranuloma venereum (LGV) recombinant strain possessing a non-LGV ompA genotype. Here, culture-independent genome sequencing confirms its circulation in Europe, Middle East, and North America, and unveils emergence of antibiotic resistance. Broad surveillance is needed.

Viral genetics and transmission dynamics in the second wave of mpox outbreak in Portugal and forecasting public health scenarios.

In 2023, a second wave of the global mpox epidemic, which is mainly affecting men who have sex with men (MSM), was observed in some countries. Herein, we benefited from a large viral sequence sampling (76/121; 63%) and vast epidemiological data to characterise the re-emergence and circulation of the Monkeypox virus (MPXV) in Portugal during 2023. We also modelled transmission and forecasted public health scenarios through a compartmental susceptible-exposed-infectious-recovered (SEIR) model. Our results suggest that the 2023 mpox wave in Portugal resulted from limited introduction(s) of MPXV belonging to C.1.1 sublineage, hypothetically from Asia, followed by sustained viral transmission and potential exportation to other countries. We estimated that the contribution of the MSM high sexual activity group to mpox transmission was 120 (95% CrI: 30-3553) times higher than that of the low sexual activity group. However, among the high sexual activity group, vaccinated individuals likely contributed approximately eight times less [0.123 (95% CrI: 0.068-0.208)] than the unvaccinated ones. Vaccination was also linked to potential reduced disease severity, with a Mpox Severity Score of 6.0 in the vaccinated group compared to 7.0 in unvaccinated individuals. Scenario analysis indicated that transmission is highly sensitive to sexual behaviour, projecting that a slight increase in the MSM sub-population with high sexual activity can trigger new mpox waves. This study strongly supports that continued vaccination, targeted awareness among risk groups and routine genomic epidemiology is needed to anticipate and respond to novel MPXV threats (e.g. global dissemination of clade I viruses).

An Atypical Rash in Disseminated Herpes Zoster: A Case Report.

Disseminated cutaneous herpes zoster (DCHZ) is an atypical presentation of herpes zoster (HZ) that mainly affects immunosuppressed patients. Given the potential risk for visceral fatal involvement, prompt recognition of this condition is crucial. In this case report, we present the case of a 90-year-old male with chronic lymphocytic leukemia under chlorambucil treatment who presented to the emergency department with multiple, converging, crusted papules on his face. He was misdiagnosed with a drug eruption and hospitalized after switching the antibiotic therapy. After one week, the lesions spread in a cephalocaudal pattern, affecting both the trunk and limbs, following which the Dermatology team was consulted. We performed an HZV smear test and initiated acyclovir. Unfortunately, the test was positive, and DCHZ was confirmed. The patient died one week later due to pneumonitis which evolved into a severe acute respiratory distress syndrome.

Rectal shedding of monkeypox virus in a patient coinfected with Chlamydia trachomatis and Neisseria gonorrhoeae: a case report.

BACKGROUND: Infection by the monkeypox virus classically causes a cutaneous rash that is preceded by fever and lymph node swelling, as well as other nonspecific systemic symptoms. A recent outbreak occurred and spread in Europe and other regions, especially among patients who declare themselves as men who have sex with men. Current reports have shown that cutaneous lesions may be limited to the anogenital area. We report on a case of proctitis caused by monkeypox virus, without visible typical lesions of this virus. CASE PRESENTATION: A 29-year-old Caucasian male presented with a monkeypox virus proctitis that recurred after treatment for a documented Neisseria gonorrhoeae and Chlamydia trachomatis coinfection, likely acquired at the same time. The proctitis was preceded by fever and a swollen inguinal lymph node, and was associated with a hemorrhoid. The monkeypox virus polymerase chain reaction of a rectal swab documented high viral loads, although no typical lesion was visible. After resolution of the rectitis, the patient developed a single dermatome herpes zoster, despite the absence of usual risk factors. The patient evolved well without further specific treatment. CONCLUSION: This case shows that monkeypox virus can be responsible for proctitis, without any typical lesion, along with the important rectal shedding of the virus. It raises the concern of contagion during anal intercourse through body fluids and gives further credit that monkeypox virus can be a sexually transmitted infection. This should prompt routine rectal screening in patients with proctitis accompanied by fever and swollen lymph nodes, and in patients who have a history of unprotected receptive anal sex, even in presence of other sexually transmitted infections, and especially during a monkeypox virus outbreak. The potential link between monkeypox virus infection and shingles warrants further investigations.

Demographic and Clinical Characteristics of Mpox Patients Attending an STD Clinic in Lisbon.

Mpox is a viral disease caused by the monkeypox virus, which marked the year of 2022 with a global outbreak. While previously considered to be a zoonosis of almost exclusive animal-to-human transmission, the current outbreak has been attributed to human-to-human transmission, particularly sexual transmission. As a new sexually transmissible disease, we studied the epidemiological and clinical features, as well as the concomitant occurrence of other sexually transmissible diseases, treatment approach, and outcome of our 291 patients, in the current outbreak. We found a total of 169 concomitant sexually transmissible infections of bacterial and viral origins, corresponding to 107 patients. Neisseria gonorrhoeae was the most common agent, particularly in the anal location. With this work, we emphasize the need for a thorough epidemiological and medical history, as well as a concomitant complete laboratorial screening for other STIs in patients with confirmed or suspected mpox.

Viral genetic clustering and transmission dynamics of the 2022 mpox outbreak in Portugal.

Pathogen genome sequencing during epidemics enhances our ability to identify and understand suspected clusters and investigate their relationships. Here, we combine genomic and epidemiological data of the 2022 mpox outbreak to better understand early viral spread, diversification and transmission dynamics. By sequencing 52% of the confirmed cases in Portugal, we identified the mpox virus sublineages with the highest impact on case numbers and fitted them into a global context, finding evidence that several international sublineages probably emerged or spread early in Portugal. We estimated a 62% infection reporting rate and that 1.3% of the population of men who have sex with men in Portugal were infected. We infer the critical role played by sexual networks and superspreader gatherings, such as sauna attendance, in the dissemination of mpox virus. Overall, our findings highlight genomic epidemiology as a tool for the real-time monitoring and control of mpox epidemics, and can guide future vaccine policy in a highly susceptible population.

Epidemiological impact of the human papillomavirus vaccination program on genital warts in Portugal: A retrospective, chart review study.

BACKGROUND: The quadrivalent human papillomavirus (HPV) vaccine was introduced in the Portuguese National Immunization Program in October 2008, targeting 13-year-old girls. This study aimed at evaluating the impact of HPV vaccination on the epidemiology of genital warts (GWs) in Portugal. METHODS: Observational, retrospective chart review study conducted at two free-of-charge walk-in sexually transmitted diseases (STD) clinics in Lisbon region. The medical records of all patients attending a first STD consultation at the study centers between May 2006 and December 2017 (observation period) were reviewed. The number of patients diagnosed with GWs and/or chlamydial infection at each year was documented and used to determine yearly prevalence of both conditions throughout the observation period. We broke down the observation period into pre-vaccination (May 2006 to December 2008) and vaccination (January 2009 to December 2017) periods. RESULTS: Most patients were male (69.5%) and aged ≥ 25 years (78.1%). The majority of male patients were men who have sex with women (62.0%). Marked decreases in the prevalence of GWs between the last year of the pre-vaccination period (2008) and the last year of the observation period (2017) were found for female patients aged ≤ 19 and 20-24 years (86.8% and 77.4%, respectively). Lower decreases were observed for male patients of the same age groups (38.5% and 19.3%, respectively). GWs prevalence increased among patients ≥ 25 years (9.7% and 14.7% among female and male patients, respectively). Overall prevalence of chlamydial infection increased by 75.9% between 2008 and 2017. CONCLUSIONS: This study contributes to the body of evidence showing that public HPV vaccination programs are effective in reducing the prevalence of GWs among vaccine-eligible patients. HPV vaccination program may significantly reduce the burden associated with GWs in Portugal.

Drug-induced Sweet's syndrome by aceclofenac.

Sweet's syndrome (SS) or acute febrile neutrophilic dermatosis is a reactive process that presents in different clinical settings and ranges from classical (idiopathic), malignancy associated or drug induced. The authors describe a 51-year-old Caucasian woman referred to our department with a 3-day history of pseudovesicular reddish papules on her neck, upper trunk and limbs. Two days prior to the eruption, aceclofenac 100 mg every 8 h was initiated for lower back pain. She also complained of high fever (39°C), arthralgias and general malaise. Laboratory evaluation showed an elevation of erythrocyte sedimentation rate and C reactive protein. A biopsy specimen of skin lesions showed throughout the upper reticular dermis a dense infiltrate of mature neutrophils. Aceclofenac was discontinued and oral prednisolone (0.5 mg/kg) was started. Fever resolved within 48 h, whereas cutaneous lesions cleared within the first week. No relapse was noted after a 6-month follow-up period. Drug-induced SS by aceclofenac diagnosis was sustained by the presence of all the five diagnostic criteria for drug-induced SS presented by Walker and Cohen in 1996. Several hundred cases of SS have been reported in the literature. However, drug-induced SS represent overall less than 5% of all cases, mostly as isolated clinical cases. Reports of nonsteroidal anti-inflammatory drug-induced SS include diclofenac, celecoxib and rofecoxib. Our patient represents the first case of aceclofenac-induced SS and illustrates the need to enquire about recent drugs in a patient with suspicion of SS.

[A rare presentation of kidney allograft intolerance syndrome: Bullous pemphigoid]. / Une présentation rare du syndrome d'intolérance au greffon renal : la pemphigoïde bulleuse.

Bullous pemphigoid is an autoimmune bullous cutaneous disease. We report the case of a 60 year-old male patient whose kidney allograft failed and was on hemodialysis for the previous 16 months. After tapering immunosuppressive medication, he presented simultaneous bullous eruption and kidney allograft intolerance syndrome. Investigation showed a positive BP180 anti-basement membrane zone antibody and skin biopsy was consistent with bullous pemphigoid. The patient was treated with corticotherapy and bullous pemphigoid resolved. The development of new onset diabetes and concerns over long term immunosuppression, halted the decision to continue corticotherapy and the patient underwent graft nephrectomy, with resolution of the kidney allograft intolerance syndrome without recurrence of the bullous disease. The occurrence of bullous pemphigoid in patients with failed renal allograft is rare, with only eleven cases reported in literature. This case illustrates how graft nephrectomy can provide a definitive cure to bullous pemphigoid in this setting.