Infectious Disease

Monkeypox should be considered in high-risk populations with neurologic symptoms

September 27, 2022

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Monkeypox should be considered in high-risk populations who present with neurologic symptoms, warranting the need for serology and PCR testing of blood and spinal fluid, researchers wrote in JAMA Neurology.

B. Jeanne Billioux, MDa staff clinician and head of the Program in International Neuroinfectious Diseases at NIH National Institute of Neurological Disorders and Stroke, and colleagues conducted a literature review of known neurologic complications of smallpox, which includes encephalitis, transverse myelitis and acute disseminated encephalomyelitis, as well as known neurologic complications of monkeypox, such as headaches and mood disorders.

Source: CDC.gov.

“In the wake of the current multinational outbreak of monkeypox, it is evident that many aspects of this disease are understudied,” Billioux and colleagues wrote. “This includes neurologic complications and sequelae and their management.”

According to researchers, monkeypox virus was first isolated in 1958 in Denmark, and while it was similar to smallpox virus in microscopic morphology, other biological characteristics designated it as a new species. In 1970, the first human monkeypox infections were identified in the Democratic Republic of Congo and other western African countries. Since May 2022, there has been an international outbreak with more than 40,000 cases reported in more than 80 countries.

According to the authors, few neurologic complications of monkeypox have been described. Headache is a common presentation and mood disturbance, including depression and anxiety, and neuropathic pain are frequent.

Encephalitis is rare with monkeypox, although three cases have been reported in the current outbreak — two in Spanish men and one in a young male Indian patient. All three died.

Because monkeypox is spread through sexual and close contact, the authors wrote that investigating for other STDs is critical, and all patients should undergo serology or PCR testing of vesicular fluid through a local health department, as recommended by WHO. If monkeypox-related neuroinvasive disease is suspected, viral PCR should be attempted in cerebrospinal fluid.

“It is important to review the literature for not only [monkeypox] but also other orthopoxviruses, such as smallpox virus, to better understand the potential of these complications,” the authors wrote. “To date, few major neurologic complications have been reported with the current outbreak. However, based on known neurologic complications of orthopoxviruses, we must be prepared for the possibility of viral encephalitis, myelitis, [acute disseminated encephalomyelitis]Guillain-Barré syndrome, neuropathic pain and others, and treat them accordingly.”

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