Background

In May, 2022, several European countries reported autochthonous cases of monkeypox, which rapidly spread globally. Early reports suggest atypical presentations. We aimed to investigate clinical and virological characteristics of cases of human monkeypox in Spain.

Methods

This multicentre, prospective, observational cohort study was done in three sexual health clinics in Madrid and Barcelona, Spain. We enrolled all consecutive patients with laboratory-confirmed monkeypox from May 11 to June 29, 2022. Participants were offered lesion, anal, and oropharynx swabs for PCR testing. Participant data were collected by means of interviews conducted by dermatologists or specialists in sexually transmitted infections and were recorded using a standard case report form. Outcomes assessed in all participants with a confirmed diagnosis were demographics, smallpox vaccination, HIV status, exposure to someone with monkeypox, travel, mass gathering attendance, risk factors for sexually transmitted infections, sexual behaviour, signs and symptoms on first presentation, virological results at multiple body sites, co-infection with other sexually transmitted pathogens, and clinical outcomes 14 days after the initial presentation. Clinical outcomes were followed up until July 13, 2022.

Findings

181 patients had a confirmed monkeypox diagnosis and were enrolled in the study. 166 (92%) identified as gay men, bisexual men, or other men who have sex with men (MSM) and 15 (8%) identified as heterosexual men or heterosexual women. Median age was 37·0 years (IQR 31·0–42·0). 32 (18%) patients reported previous smallpox vaccination, 72 (40%) were HIV-positive, eight (11%) had a CD4 cell count less than 500 cells per μL, and 31 (17%) were diagnosed with a concurrent sexually transmitted infection. Median incubation was 7·0 days (IQR 5·0–10·0). All participants presented with skin lesions; 141 (78%) participants had lesions in the anogenital region, and 78 (43%) in the oral and perioral region. 70 (39%) participants had complications requiring treatment: 45 (25%) had a proctitis, 19 (10%) had tonsillitis, 15 (8%) had penile oedema, six (3%) an abscess, and eight (4%) had an exanthem. Three (2%) patients required hospital admission. 178 (99%) of 180 swabs from skin lesions collected tested positive, as did 82 (70%) of 117 throat swabs. Viral load was higher in lesion swabs than in pharyngeal specimens (mean cycle threshold value 23 [SD 4] vs 32 [6], absolute difference 9 [95% CI 8–10]; p<0·0001). 108 (65%) of 166 MSM reported anal-receptive sex. MSM who engaged in anal-receptive sex presented with proctitis (41 [38%] of 108 vs four [7%] of 58, absolute difference 31% [95% CI 19–44]; p<0·0001) and systemic symptoms before the rash (67 [62%] vs 16 [28%], absolute difference 34% [28–62]; p<0·0001) more frequently than MSM who did not engage in anal-receptive sex. 18 (95%) of 19 participants with tonsillitis reported practising oral-receptive sex. The median time from onset of lesions to formation of a dry crust was 10 days (IQR 7–13).

Interpretation

In our cohort, monkeypox caused genital, perianal, and oral lesions and complications including proctitis and tonsillitis. Because of the variability of presentations, clinicians should have a low threshold for suspicion of monkeypox. Lesion swabs showed the highest viral loads, which, combined with the history of sexual exposure and the distribution of lesions, suggests close contact is probably the dominant transmission route in the current outbreak.

Funding

None.

中文翻译：

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西班牙确诊的人猴痘病毒病例的临床表现和病毒学评估：一项前瞻性观察队列研究

背景

2022 年 5 月，多个欧洲国家报告了本土猴痘病例，并迅速在全球蔓延。早期报告提示非典型表现。我们旨在调查西班牙人猴痘病例的临床和病毒学特征。

方法

这项多中心、前瞻性、观察性队列研究是在西班牙马德里和巴塞罗那的三个性健康诊所进行的。我们连续招募了 2022 年 5 月 11 日至 6 月 29 日期间所有经实验室确诊的猴痘患者。向参与者提供病变、肛门和口咽拭子以进行 PCR 检测。参与者数据是通过皮肤科医生或性传播感染专家进行的访谈收集的，并使用标准病例报告表进行记录。在所有确诊参与者中评估的结果包括人口统计学、天花疫苗接种、艾滋病病毒感染状况、接触猴痘患者、旅行、群众集会出席情况、性传播感染的危险因素、性行为、首次就诊时的体征和症状、首次就诊时的病毒学结果多个身体部位，合并感染其他性传播病原体，以及首次出现后 14 天的临床结果。临床结果随访至 2022 年 7 月 13 日。

发现

181 名患者确诊为猴痘并被纳入研究。166 人 (92%) 被认定为男同性恋者、双性恋男性或其他男男性接触者 (MSM)，15 人 (8%) 被认定为异性恋男性或异性恋女性。中位年龄为 37·0 岁 (IQR 31·0–42·0)。32 名 (18%) 患者报告曾接种过天花疫苗，72 名 (40%) 为 HIV 阳性，8 名 (11%) 的 CD4 细胞计数低于 500 个细胞/μL，31 名 (17%) 被诊断为同时患有性病传播感染。中位孵育时间为 7·0 天 (IQR 5·0–10·0)。所有参与者均出现皮肤损伤；141 名 (78%) 参与者在肛门生殖器区域有病变，78 (43%) 名参与者在口腔和口周区域有病变。70 名 (39%) 参与者有需要治疗的并发症：45 名 (25%) 患有直肠炎，19 名 (10%) 患有扁桃体炎，15 名 (8%) 患有阴茎水肿，六名 (3%) 出现脓肿，八名 (4%) 出现皮疹。三名 (2%) 患者需要住院。收集的 180 个皮肤损伤拭子中有 178 个（99%）检测呈阳性，117 个咽拭子中有 82 个（70%）呈阳性。病变拭子中的病毒载量高于咽部标本（平均循环阈值 23 [SD 4]vs 32 [6]，绝对差异 9 [95% CI 8–10]；p<0·0001)。166 名 MSM 中有 108 名 (65%) 报告了接受肛交的性行为。接受肛门性行为的 MSM 出现直肠炎（108 人中有 41 人 [38%]对58 人中有 4 人 [7%]，绝对差异 31% [95% CI 19–44]；p<0·0001）和全身症状出疹前（67 [62%]对16 [28%]，绝对差异 34% [28–62]；p<0·0001）比未进行肛交性行为的 MSM 更频繁。19 名扁桃体炎参与者中有 18 名 (95%) 报告进行过口交性行为。从病变开始到形成干痂的中位时间为 10 天 (IQR 7–13)。

解释

在我们的队列中，猴痘引起了生殖器、肛周和口腔的损伤和并发症，包括直肠炎和扁桃体炎。由于表现的可变性，临床医生应该对猴痘的怀疑有一个较低的阈值。病变拭子显示出最高的病毒载量，结合性接触史和病变分布，表明密切接触可能是当前疫情的主要传播途径。

资金

没有任何。