The CDC has reported two cases of encephalomyelitis associated with monkeypox

Two men in the United States developed encephalomyelitis — the inflammation of the brain and spinal cord — after developing monkeypox, according to a new report published by the Centers for Disease Control and Prevention (CDC). Both patients, who were previously healthy and in their 30s, survived, although the report states that both used walking aids on discharge from the hospital.

Neurological complications of monkeypox virus infection are rare, although encephalitis has been reported previously. The death associated with monkeypox in Spain earlier this summer was caused by both patients developing encephalitis, said Isabel Gade, director of the World Health Organization’s Spanish National Institute of Microbiology. Power point. WHO also menus Encephalitis as a possible classification for monkeypox.

Although neurological complications of acute monkeypox virus (MPXV) infection are rare, suspected cases should be reported to state, tribal, local or regional health departments to improve understanding of the range of clinical manifestations and treatment options for MPXV infection during the current outbreak. Lead writing is Daniel Pastola, MD, a neurologist and epidemiologist at the University of Colorado School of Medicine in Aurora, and co-authors.

The report was published September 13 in the Centers for Disease Control Weekly morbidity and mortality report .

Patient A

The first case (Patient A) occurred in a previously healthy homosexual male in Colorado. He was not vaccinated against monkeypox or smallpox. In July 2022, he reported fever, chills, and malaise. After 3 days, he developed a rash on his face that extended to his limbs and scrotum. The results of the polymerase chain reaction (PCR) test subsequently confirmed MPXV infection.

Nine days after the onset of initial symptoms, patient A developed weakness and worsening numbness in his left arm and leg as well as difficulty urinating. After hospitalization, MRI showed lesions in the brain and spine. There was no evidence of monkeypox virus DNA in the cerebrospinal fluid.

Patient A was treated orally tekovirimat (TPOXX), intravenously (IV) methylprednisoloneImmunoglobulin and penicillin. After two weeks, improvement in limb weakness and numbness subsided, with weakness continuing in the left leg.

The patient’s leg weakness improved further after starting plasma therapy, and the rash cleared up within 3 weeks. The patient was discharged to the outpatient clinic for rehabilitative therapy, and at his one-month follow-up, he was using a walking assistive device.

patient b

The second case (Patient B) occurred in a previously homosexual man in DC. He was not vaccinated against monkeypox, and it is not known if he received the smallpox vaccine. In July 2022, he developed a fever and muscle aches, followed by a rash on his face, limbs, trunk, and perianal area. The results of the PCR test subsequently confirmed MPXV infection.

Five days after onset of symptoms, he began to have bowel and bladder incontinence and progressive flaccid weakness in both legs and was hospitalized. Over the next two days, he developed an altered mental state and a runny nose, was intubated and transferred to the intensive care unit. MRI showed lesions in the brain and spine, and computed tomography revealed rectal thickening and swollen pelvic lymph nodes, although the latter was thought to be related to monkeypox infection. There was no evidence of monkeypox virus DNA in the cerebrospinal fluid.

Patient B was treated with IV TPOXX and methylprednisolone. Despite improved cognition, there was no immediate improvement in muscle weakness. The patient then started taking intravenous immunoglobulin, but the treatment was stopped after 2 days because the patient developed a high fever.

Then his care team started plasmapheresis and the patient improved dramatically. After five treatments, patient B was extubated, he could talk and follow commands, and his lower limb weakness had improved. The rash healed in 5 weeks. He was given the fourth rituximab, which is a monoclonal antibody therapy, and is being discharged for inpatient rehabilitation. On discharge from the hospital, he was using a walking aid.

The best treatment is not clear

It is not known how encephalitis developed in either of these conditions, the CDC report notes, so the best treatment approach is unclear.

Tecovirimat is recommended for acute monkeypox disease, the authors wrote, and corticosteroids may be considered if there is significant edema, demyelination, or acute disseminated acute encephalomyelitis-like disease. However, the authors wrote: “The immunosuppressive benefits and risks must be weighed during active infection.” Intravenous immunoglobulin therapy or plasmapheresis therapy may also be considered.

“Physicians and public health professionals should be aware of the range of possible clinical presentations for MPXV and potential treatments,” the authors continue. “Suspected cases should be reported to state, tribal, local or regional health departments to improve understanding of the range of clinical manifestations of MPXV and treatment options.”

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