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Case Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_765_2022

Monkeypox disease in India: Unusual clinical presentation

Department of Dermatology, Maulana Azad Medical College, New Delhi, India
Medicine, Maulana Azad Medical College, New Delhi, India
Corresponding author: Dr. Bijaylaxmi Sahoo, Department of Dermatology, Maulana Azad Medical College, New Delhi, India. blsahooacad@gmail.com
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This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Sahoo B, Kumar S, Monalisa K, Solanki B, Relhan V. Monkeypox disease in India: Unusual clinical presentation. Indian J Dermatol Venereol Leprol. doi: 10.25259/IJDVL_765_2022

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 15]. 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.

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.
Figure 1b:
Multiple well-defined erosions present over the base of penis with erythematous base and marginal re-epithelization.
Figure 2a:
Multiple discrete to coalescent ulcers present over the scrotum and inner aspect of bilateral thighs with erythematous base and marginal hyperpigmentation.
Figure 2b:
Few scattered umbilicated papules present over the chest and abdomen.
Figure 3a:
Multiple skin-coloured, umbilicated papules and vesiculopustular lesions present over the forehead.
Figure 3b:
Few erythematous papules present over the palm and soles.
Figure 4a:
Multiple skin-coloured umbilicated papules present over the oral mucosa with overlying greyish slough.
Figure 4b:
Multiple umbilicated papules and erosions present over the clitoris, labia majora and minora.
Figure 5:
Multiple umbilicated papules present over the back and right arm.
Table 1: Summary of the 12 patients with Monkeypox disease
Case Age & Sex Onset site/lesion count Nationality Sexual behaviour/partners/marital status Last sexual contact H/o international travel/months Constitutional features Lesions type Mucosa Palm and sole Lymphadenopathy HIV/VDRL/Hep B,C
Confirmed cases
1 34 M Genitalia ≈30 Indian Heterosexual (single regular partner)/married 15 days back, protected No Fever, lethargy, low mood VP, erosions, crusting, umbilication, ulcers + NR
2 34 M Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 month back, unprotected No Lethargy, difficulty in swallowing, low mood VP, erosions, thick crusted ulcers Oral erosion+ & pharyngitis, genital erosion+ + B/L submental, retro-auricular LNs NR
3 35 M Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 month back, unprotected No Fever, lethargy. VP, erosions, crusted ulcers _ + B/L submandibular, inguinal NR
4 31 F Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 year back 5 months back to Nigeria Fever, lethargy, difficulty in swallowing VP, erosions, crusted ulcers, umbilication Oral erosion, Genital erosion+ + B/L Inguinal NR
5 22 F Foot ≈20 Nigerian Heterosexual (2 sexual partners)/unmarried 4 days back 35 days back to Nigeria Fever, difficulty in swallowing VP, erosions, crusting, umbilication Oral erosion, genital erosion+ + - NR
6 25 F Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 month back, protected 1 month back to Nigeria Fever, difficulty in swallowing VP, erosions, crusted ulcers genital erosion+ - - NR
7 24 F Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 weekback, protected 4 month back to Nigeria Fever, difficulty in swallowing VP, erosions, crusted ulcers genital erosion+ - B/L inguinal LN HIV +
8 24 M Hand ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 weekback, unprotected 3 month back to Nigeria Fever, difficulty in swallowing VP, erosions, crusted ulcers Whitish papule over tonsils + Left inguinal LN NR
9 24 M Hand ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 month back protected - Fever, difficulty in swallowing VP, erosions, crusted ulcers genital erosion+ + - NR
10 30 F Genitalia ≈20 Nigerian Denied - 4 month back to Nigeria Difficulty in swallowing VP, erosions, crusted ulcers genital erosion+ - - NR
11 30 F Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 month back, protected - - VP, erosions, crusted ulcers genital erosion+ + Left axillary LN NR
12 22 F Genitalia ≈20 Nigerian Heterosexual (single regular partner)/unmarried 1 weekback, protected 7 month back to Nigeria Fever, difficulty in swallowing VP, erosions, crusted ulcers genital erosion+ + B/L submandibular, inguinal NR

VP: Vesicopustules, LN: Lymphnodes, NR: non-reactive, B/L: Bilateral

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.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

References

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