September 23, 2022
5 minutes to read
Source / Disclosures
Healio . Interviews
Ramprasad did not make any relevant financial disclosures.
As the number of monkeypox cases continues to expand globally, a series of potential new clinical symptoms are emerging, a development that may put gastroenterologists at the forefront of care for this evolving outbreak.
The United States has so far recorded more than 24,572 confirmed cases Monkeypox/Orthopoxvirus Since May, according to the CDC. With 64,916 cases worldwide, including 64,336 in countries where the disease is not endemic, on July 23, the Director-General of the World Health Organization announced. Monkeypox outbreak Public Health Emergency of International Concern – Same designation as for SARS-CoV-2 in January 2020.
“Historically, monkeypox was thought to be a virus related to smallpox without significant gastrointestinal involvement,” Chethan Ramprasad, MD, Fellow of the Goethe-Institut at the University of Pennsylvania, told Helio. “It was thought to be endemic to parts of Africa with potential for transmission to the United States and Europe.”
While the most widely discussed symptoms of monkeypox include fever, malaise, lymphadenopathy and rash, a recent study by Thornhill and colleagues in The New England Journal of Medicine revealed distinctive features in the group of patients not included in the internationally accepted case definitions of monkeypox: primary genital, anal, and oral lesions.
Although current definitions of monkeypox advise suspicion of any ‘unusual’ rash, this does not cover the full range of manifestations, particularly given that single skin lesions of the genitals and lesions of the palms and soles are easily diagnosable. incorrectly as syphilis or another sexually transmitted disease.
Similarly, a study by Patel and colleagues in BMJ reported that approximately half of the patient group showed exclusively mucocutaneous manifestations or developed systemic symptoms after, rather than before, the onset of lesions. Patients commonly reported penile swelling and rectal pain among their symptoms, features not widely described in the current literature, although cited as frequent causes of hospitalization.
“Rectal pain and penile edema were the most common presentations requiring hospitalization in this group, however these symptoms are not currently included in public health messages,” Atish Patel, MD, from Guys and St. Thomas’ NHS Foundation Trust and colleagues wrote. “We recommend that clinicians consider monkeypox infection in those who present with these symptoms. Those with confirmed monkeypox infection with extensive lesions of the penis or severe rectal pain should be considered for ongoing review or inpatient management.”
Ramprasad noted that these perianal and peri-rectal lesions are new symptoms seen “in connection with the May 2022 outbreak”.
Unique GI properties
in their studies in Colon and rectal diseasesRamprasad and colleagues note that with an incubation period of days to 3 weeks, the site of inoculation is often the first site of lesions, which may also be preceded by a “prodromal fever or constellation of fatigue and muscle aches”.
Although the appearance of the lesion is most commonly observed outside the rectum, the current presentation of symptoms has evolved to include internal lesions as well.
“Recently, and perhaps more importantly to note, there can be presentations in patients with lesions in the rectum only,” Ramprasad said. “It is much easier to identify a patient as being at risk of developing monkeypox if there are external lesions because it is easier for the doctor to see them; [however,] If the lesions are inside the rectum, it’s hard to diagnose because it’s hard to tell what’s going on.”
He added that these symptoms can be “incredibly painful and difficult for patients to deal with in the rectum and anus when there is severe pain.”
Specifically, the lesions are exacerbated during bowel movements, when the muscles move in coordination with each other, which can exacerbate constipation, and the potential for ulceration, tears and bleeding.
Who is at risk?
According to current CDC data, gay, bisexual, and other men who have sex with men make up the majority of cases in the ongoing monkeypox outbreak; Data from Patel and colleagues reported that, of the 1,735 patients diagnosed with monkeypox in the UK, 96% were identified as belonging to this population.
Although transmission through saliva has been confirmed, direct contact with the pests and potential semen is limited, and anyone, regardless of sexual orientation or gender identity, can be at risk of exposure to monkeypox.
“What we’ve seen so far are patients who have sex with men, but transmission is still being worked out in full detail,” Ramprasad said. “It is believed to be sexually transmitted, but there could be transmission through airborne particles or other body fluids that would not be limited to this specific group. If there is an unclear diagnostic puzzle and enough story to worry about monkeypox, it should be tested.”
An important consideration to note is the stigma associated with a patient’s conversations with the provider about sexual health and preferences. Ramprasad believes this is a common drawback, especially since many patients may not want to disclose certain information about themselves for fear of being at risk.
“I don’t think it suffices to say that only men who have sex with men are the only people at risk because even that definition is quite loose; it could be a variety of people,” he said. “All clinicians who see patients with rectal pain or perianal lesions should consider diagnosing monkeypox and should consider testing these patients. We need to be careful about who may be at risk for this infection.”
Testing and suggested management
Besides clinical conclusion, definitive diagnosis of monkeypox requires PCR testing. Adequate specimens include dry lesion swabs and rectal swabs, similar to an STD test. In severe cases of unexplained rectal bleeding or diarrhea, Ramprasad recommended an endoscopy to collect biopsy samples.
“If the bleeding is severe enough for endoscopic or endoscopic monitoring, it should be followed up,” he said. “If the diagnosis is unclear and that person does not have high-risk demographic characteristics, it should also be scoped so that we can better understand the cause of their symptoms.”
After diagnosing monkeypox, Ramprasad and colleagues cited supportive care for perianal and rectal lesions as essential for first-line management. Specifically, this includes a combination of stool softeners and pain relievers; They recommended a daily dose of polyethylene glycol and acetaminophen for minor pain and a short course of opioids for severe anal pain. Additional pain management strategies include analgesics such as warm sitz baths and topical lidocaine.
Ramprasad noted that the debate on the use of the antiviral drug tecofermatate (TPOXX) has proven beneficial among some patient groups for pest management; Current indications include immunocompromised patients, those with severe disease or lesions in sensitive areas.
“It remains unclear which group of patients would benefit most from antiviral therapy, but TPOXX is thought to shorten disease duration and viral shedding and, in our anecdotal experience, helped manage rectal pain in the identification of rectal ulcers/lesions arising from monkeypox infection,” Ramprasad and colleagues wrote. These perianal and rectal lesions often take several days to weeks for complete resolution. Treatment with TPOXX may speed healing, but it is not known how long it takes for the lesions to no longer become contagious.”
TPOXX has not yet been approved by the FDA but is being evaluated in an investigational new drug application.
“What’s important here is that this is a population that is susceptible to monkeypox,” Ramprasad said. “They are a stigmatized people who need a very serious level of care in terms of treatment and diagnostic tests; it is very important for every practitioner to view the patient as an individual, as someone who has his or her own story in the presentation.”
He added: “There is a long history of treating patients with a history of MSM; especially with the AIDS and HIV epidemic, there are a lot of lessons to be learned in terms of treating and listening to stigmatized societies. The thing we can all do Its better to listen.”
Editor’s note: The case numbers in this story reflect the updated numbers reported by the CDC on Friday, September 23, 2022.