In a recent case report published in the Journal of Infection, researchers highlighted the virologic and clinical features of monkeypox virus (MPXV) infections with ocular involvement.
Study: Ocular involvement in monkeypox: description of an unusual presentation during the current outbreak. Image credit: MIA Studio/Shutterstock
In the current 2022 MPXV outbreak, cases of MPX have been reported predominantly among men who have sex with men (MSM) with no epidemiological association with endemic nations. MPX is usually a mildly intense, self-limiting disease with rare complications and does not require specific antiviral agents to improve disease outcomes.
Antiviral therapeutic agents have been administered in cases with greater severity or complications and lesions in sites with greater risk of MPX sequelae. In particular, ocular complications have been rarely reported in current outbreaks compared to those identified in endemic nations.
About the case report
In the present case report, investigators described a case of MPX with ocular complications identified in May 2022 in an MSM patient in Italy.
A 26-year-old man presented to an outpatient department with papules (n = 2) in the region above the pubic area and was diagnosed with MPX by real-time polymerase chain reaction (PCR) at from specimens of dermatological lesions. She had protected sexual history five days prior to the outpatient visit with a man diagnosed as MPXV-positive by MPXV-deoxyribonucleic acid (DNA)-based real-time PCR on conjunctival and eyelid swabs and by isolation of MPXV in cell cultures .
Two days after the initial visit, the patient was hospitalized with malaise, fever, headache, enlarged inguinal nodes, and several right-sided eyelid papules with progressive conjunctival and periorbital involvement. Based on the clinical presentation, a bacterial superinfection was suspected and therefore topical steroids were administered with intravenous (IV) antibiotics.
Over time, lesion counts in the ocular fornix and lower and upper eyelids were elevated, and the patient also had hyperemia in the conjunctival region and edema in the periorbital region. Subsequently, swabs were obtained from the conjunctival and periorbital lesion areas and analyzed for the presence of MPXV DNA using real-time PCR assays, i.e., real-star orthopoxvirus PCR and PCR-based in the TNF (tumor necrosis factor) receptor gene for MPXV. screening and confirmation, respectively.
In addition, the MPXV quantification cycle (Cq) in the MPXV-positive samples was also evaluated. Conjunctival and eyelid samples were reported as MPXV positive by both PCR assays. After inoculation of the conjunctival sample (swab) into Vero E6 cells, cytopathic effects (CPE) were observed within two days, and viral replication was observed after two days, three days, and four days. MPXV isolated from conjunctival swabs was found to be replication competent in the absence of bacterial growth.
The patient was given IV cidofovir (five mg/kg twice a week) with measures to improve fluid intake and oral probenecid) and eye drops containing vitamin A and anti-inflammatory agents with tapering and subsequent stopping of steroid supplements. Cidofovir was administered to prevent the risk of visual impairment in view of the worsening clinical scenario.
The clinical condition gradually improved after treatment with asynchronous evolution of the lesion followed by complete resolution at two months after the onset of MPX. The slow rate of intraocular clearance of MPXV and complete recovery indicated the partial contribution of the antiviral activity of cidofovir to the resolution of clinical signs and symptoms.
Conclusions
The findings of the study emphasize the development of possible ocular lesions in cases of MPX identified in non-endemic settings. The authors of the present study believe that the case report is one of the first of its kind to describe ocular lesions in MPX due to infectious and replication-competent MPXV, as observed in viral isolation experiments .
Contrary to the findings of previous studies, systemic symptomatology and ocular lesions were reported after the development of dermatological lesions in the present report, indicative of MPXV autolocalization in ocular tissues based on the spread of MPXV from ‘local inoculums. The findings support the application of strict hygiene measures to reduce MPXV transmission. Furthermore, the findings of slow MPXV clearance and clinical recovery after IV cidofovir administration may have implications for MPXV transmission and the pathophysiology of ocular involvement in MPX.
Journal reference:
- Mazzotta V, Mondi A, Carletti F, Baldini F, Santoro R, Meschi S, Moccione M, Gebremeskel Tekle S, Minosse C, Camici M, Vita S, Matusali G, Nicastri E, Girardi E, Maggi F, Vaia F, Antinori A, Pinnetti C. (2022). Ocular involvement in monkeypox: description of an unusual presentation during the current outbreak. Journal of infection. doi: