Monkeypox disease in India: Unusual clinical presentation

Dear Editor,

Herein, we report a case series of monkeypox (MP) disease from India. The data is presented from an MP-designated tertiary care hospital in North India, from July 2022 to October 2022.

Out of the 12 confirmed cases of MP, 5 (42%) were males and 7 (58%) were females. The median age at presentation was 28 years. In all cases, patients reported having a single sexual partner, except for one patient who had two partners, and one denied any sexual contact. Six (50%) of these patients had a history of travelling to Nigeria within the past 6 months.

Majority of the lesions observed were umbilicated papulo-pustular and crusted ulcers, predominantly located on the genitalia in every patient [Figures 1–5]. Involvement of the palms and soles were noted in 9/12 (75%) patients. In all, number of lesion count exceeded 50. Oral erosion with pharyngitis and genital erosions were present in 10 (83%) patients each, while significant lymph node enlargement was observed in 7 (58%) patients. One patient was HIV positive, while all tested negative for venereal disease reserach laboratory (VDRL), HBsAg and anti-HCV antibodies. The patients’ details are summarised in Table 1.

Close

Figure 1a:

Multiple, well-defined, round-to-oval umbilicated lesions with brownish-black thick crusting present over the base of penis, arranged singly and in groups.

Export to PPT

Close

Figure 1b:

Multiple well-defined erosions present over the base of penis with erythematous base and marginal re-epithelization.

Export to PPT

Close

Figure 2a:

Multiple discrete to coalescent ulcers present over the scrotum and inner aspect of bilateral thighs with erythematous base and marginal hyperpigmentation.

Export to PPT

Close

Figure 2b:

Few scattered umbilicated papules present over the chest and abdomen.

Export to PPT

Close

Figure 3a:

Multiple skin-coloured, umbilicated papules and vesiculopustular lesions present over the forehead.

Export to PPT

Close

Figure 3b:

Few erythematous papules present over the palm and soles.

Export to PPT

Close

Figure 4a:

Multiple skin-coloured umbilicated papules present over the oral mucosa with overlying greyish slough.

Export to PPT

Close

Figure 4b:

Multiple umbilicated papules and erosions present over the clitoris, labia majora and minora.

Export to PPT

Close

Figure 5:

Multiple umbilicated papules present over the back and right arm.

Export to PPT

MP is a rare disease caused by the monkeypox virus, genus orthopoxviridae. While the disease is endemic in Africa, in May 2022, it began spreading to non-African regions. In countries like India, where the MP disease was not reported earlier, the current outbreak is more likely linked to international travel to the affected areas.¹ On 23 July 2022, the World Health Organization (WHO) declared MP “a public health emergency of international concern.”² Currently, more than 100 countries have reported outbreaks of this disease.

India was the first country in southeast Asia to report MP in an adult male who had a history of travel to the Middle East. The patient had close contact with an MP-positive individual in the United Arab Emirates (UAE).³ About 10 days later, Delhi reported its first case (Case 1), and this patient had no recent history of international travel.⁴ While government health officials did not officially confirm community transmission of the disease in India at that time, it raised concerns about the possibility of local spread.

The disease primarily affects the adult population and begins with a prodrome of fever, lymphadenopathy, headache, malaise, chills, rigour, sore throat or cough. Skin manifestations typically appear within 1–3 days after the onset of fever, and these symptoms can persist for a duration of 2–4 weeks. The lesions usually start as macules on the face and then gradually spread centrifugally to the palm and soles. Scabs typically persist for around a week before falling off spontaneously. Upon healing, they may result in either hyperpigmented or hypopigmented atrophic or hypertrophic scars, occasionally leading to patchy alopecia, contracture, or deformities.⁵

Contrary to the classic centrifugal spread of rash in MP, we observed predominant clustering of lesions in the genital area. A similar finding was also observed by Thornhill et al.⁵, where sexual route was the most common mode of transmission of the disease in 95% of their cases. Noticeably, 97% of those patients were homosexual, 1% was heterosexual and 2% were bisexual.⁵ Another study detected MP DNA in the seminal fluid of 29 of 32 cases, although it remains unclear whether the DNA was capable of replication and further transmission.⁶ According to the United Kingdom Health Security Agency, sexual abstinence during the disease period and condom usage for 12 weeks after the scabs have fallen, are recommended precautions.⁷ In the present study, the patients denied any homosexual contact or history of contact with any suspected MP cases. However, it is important to note that the possibility of transmission through sexual contact cannot be entirely ruled out.

The patients were admitted for the purpose of isolation, confirmation of diagnosis and monitoring. All patients showed improvement with conservative treatment. Upon discharge, they were advised to use condoms for a duration of 8–12 weeks and scheduled for follow-up in the sexually transmitted infection (STI) clinic.

To conclude, the clustering of umbilicated crusted lesions over the genital area is an atypical presentation of MP disease. This raises a clinical suspicion of sexual route of transmission in the present case series, although patients denied homosexual contact, or contact with other confirmed cases of MP. In addition, the possible neurotropic nature of these viruses or their affinity for the genital region needs to be researched.