Monkeypox outbreak in Spain: clinical and epidemiological findings in a prospective cross-sectional study of 185 cases

Abstract

Background Since May 2022, a new outbreak of monkeypox has been reported in several countries, including Spain. The clinical and epidemiological characteristics of the cases in this outbreak may differ from those in earlier reports. Objectives To document the clinical and epidemiological characteristics of cases of monkeypox in the current outbreak. Methods We conducted a prospective cross‐sectional study in multiple medical facilities in Spain to describe the cases of monkeypox in the 2022 outbreak. Results In total, 185 patients were included. Most cases started with primarily localized homogeneous papules, not pustules, in the probable area of inoculation, which could be cutaneous or mucous, including single lesions. Generalized small pustules appeared later in some of them. Heterogeneous lesions occurred during this generalized phase. All patients had systemic symptoms. Less common lesions included mucosal ulcers (including pharyngeal ulcers and proctitis) and monkeypox whitlows. Four patients were hospitalized, none died. Smallpox vaccination and well‐controlled HIV disease were not associated with markers of severity. Contact during sex is the most likely mechanism of transmission. In this outbreak, cases have been described in men who have sex with men and are strongly associated with high‐risk sexual behaviours. Seventy‐six per cent of the patients had other sexually transmitted diseases upon screening. Conclusions The clinical findings in this outbreak differ from previous findings and highly suggest contact transmission and initiation at the entry site. The characterization of the epidemiology of this outbreak has implications for control. What is already known about this topic? Monkeypox eruption is described as consisting of pustules. The roles of HIV and previous smallpox vaccination in the prognosis are unknown. The transmission route was initially described as respiratory droplets and was later suggested to be via sexual contact. What does this study add? Initial lesions at the probable inoculation area were homogeneous and papular (pseudopustules). Generalized small pustules appeared later in some of them. Heterogeneous lesions occurred during this generalized phase. All patients had systemic symptoms. Less common signs included mucosal ulcers (including pharyngeal ulcers and proctitis) and monkeypox whitlows. Well‐controlled HIV and previous smallpox vaccination were not associated with severity. No patient died. The data support the hypothesis of transmission via contact during sex. Although this might change, the outbreak is currently limited mostly to men who have sex with men, with high‐risk factors for sexually transmitted diseases.

Monkeypox: Some Keys to Understand This Emerging Disease

“…In the second stage, which starts 1 to 3 days after the onset of fever, an exanthema, the typical poxviral lesions described above, develops. The lesions are itchy and can be very painful, and while typically in the previous outbreaks were seen mostly in the face (95%), the limbs, mostly in the hands and feet (75%), and the oral mucosa (70%), in the present 2022 outbreak, they are mostly in the genitalia or perineal region ( Table 1 ) [ 50 , 56 , 60 , 61 , 72 ]. Lesions in the conjunctiva are less frequent (20%) but can lead to sight-threatening keratitis [ 25 , 28 ].…”

“…Preliminary risk factors in the ongoing epidemic are: being a young male; having sex with other men; engaging in risky sexual behaviors and activities, including condomless sex, multiple sexual partners, and human immunodeficiency virus infection [ 53 , 54 , 55 , 56 ]; and a story of previous sexually transmitted infections, including syphilis [ 53 , 56 ]. In a Spanish study, 54% of the patients had had a positive diagnosis of sexually transmitted infections (STIs) in the previous months, 42% were positive for HIV, and 76% had a concomitant STI at the time of diagnosis of MPXV [ 56 ].…”

“…The possibility of sexual transmission is raising big concern, as a large number of cases have happened in men who have sex with men (MSM) [ 34 , 36 , 50 , 54 , 56 , 60 , 61 , 62 ]. The development of skin lesions and eruptions in the genital and perianal regions suggests that direct physical contact with lesions during sexual contact is a likely route of transmission [ 52 ].…”

“…The surface of the lesion progressively thins out and weakens and finally opens to free the content, full of infective viral particles, and forms a crust that eventually falls. However, in the present multi-country outbreak, dermatologists are reporting that the lesions are pseudopustular, with whitish solid content, a necrotic center, and an erythematous hale, which evolve to a more purulent, necrotized, and even ulcerative aspect [ 56 ]. As the lesion originated deep in the dermis, usually scars of pockmarks are left as a result of the infection [ 38 , 65 , 66 , 67 ].…”

“…In the first stage, which may last up to 5 days, the patient may suffer (numbers in parenthesis correspond to the present 2022 outbreak): fever (54% of the patients), intense headache (32%), backache, and myalgia (44%), as well as severe asthenia (44%). Lymphadenopathy (lymph nodes of the neck, axilla, and groin) is present in a large percentage of affected persons (56%) ( Figure 3 ) [ 23 , 50 , 56 , 59 , 69 , 70 , 71 ]. In the second stage, which starts 1 to 3 days after the onset of fever, an exanthema, the typical poxviral lesions described above, develops.…”