Exploring atypical manifestations of Mpox: Anarrative review
Keywords:
Monkey pox, Mpox, Atypical manifestations, Mpox virus, NigeriaAbstract
Mpox (formerly referred to as monkey pox), a viral infection known for its
characteristic manifestations, presents with atypical symptoms, leading to
diagnostic and management challenges. Recent outbreaks of the disease have
also revealed changes in the epidemiologic patterns of the disease with many
cases going unnoticed. These scenarios if not properly identified and addressed
can led to increased healthcare burden created by the virus. To conduct the
narrative review of the concerned literature, a comprehensive and well through
search from PUBMED, Google scholar, EMBASE and African Journal Online
Evaluating Studies was conducted from published works between 2003 to 2023.
This narrative review aims at exploring the atypical manifestations of Mpox, by
reviewing various manifestations of the disease, examining the overlying
mechanisms and factors influencing these manifestations; and more so,
assessing various clinical implications and challenges facing its management,
with the hope of suggesting future directions in tackling the clinical implications
and challenges. Regarding the atypical manifestations of Mpox, the review
focused on the neurological, dermatological, and respiratory presentations,
highlighting the diverse symptoms observed in each case. In addition, accurate
diagnosis of atypical cases is crucial and requires a high index of suspicion,
comprehensive differential diagnosis, and appropriate diagnostic testing.
Tailored strategies for treatment are essential to address the specific
manifestations observed. For future research, a focus on elucidating the
pathogenesis, identifying risk factors, improving diagnostic approaches, and
evaluating treatment strategies for atypical Mpox cases is required.
References
Manirambona E, Musa SS, Shomuyiwa DO et.
al. The monkeypox virus: A public health
challenge threatening Africa. Public Health
C h a l l e n g e s . 2 0 2 2 : 1 ( 4 ) : e 3 3
https://doi.org/10.1002/puh2.33
Bartholomew E, Kosche C, & Leslie KS. Mpox
infection presenting with morbilliform rash: A
case series. JAAD case reports. 2023; 35:
8 – 1 0 2 .
https://doi.org/10.1016/j.jdcr.2023.03.001
Happi C, Adetifa I, Mbala P, et. al. Urgent need
for a non-discriminatory and non-stigmatizing
nomenclature for monkeypox virus. PLoS Biol.
0 2 2 ; 2 0 ( 8 ) : e 3 0 0 1 7 6 9 . d o i :
1371/journal.pbio.3001769. PMID:
; PMCID: PMC9451062.
Ogoina D, Damon I, Nakoune E. Clinical review
of human mpox. Clin Microbiol Infect. 2023;
1 :S1 1 9 8 - 7 4 3 X ( 2 3 ) 0 0 4 2 2 - 6 . d o i:
1016/j.cmi.2023.09.004. Epub ahead of print.
PMID: 37704017.
Philpott D, Hughes CM, Alroy KA, et al.
Res. J. Health Sci. Vol 12(1), March 2024 78
Sokunbi and Adeyemo, 2024
Epidemiologic and clinical characteristics of
monkeypox cases—United States, May 17-July
, 2022. MMWR Morb Mortal Wkly Rep.
0 2 2 ; 7 1 ( 3 2 ) : 1 0 1 8 – 1 0 2 2 . d o i :
15585/mmwr.mm7132e3. - DOI - PMC -
PubMed
Hoffmann C, Jessen H, Boesecke C. Monkeypox
i n G e r m a n y . D t s c h A r z t e b l I n t.
;119(33–34):551–557. - PMC - PubMed.
Hoffmann C, Jessen H, Wyen C. et al. Clinical
characteristics of monkeypox virus infections
among men with and without HIV: a large
outbreak cohort in Germany. HIV Med.
;24(4):389-397. doi: 10.1111/hiv.13378.
Epub 2022 Sep 4. PMID: 36059149.PubMed
Abbasi J. Reports of asymptomatic monkeypox
suggest that, at the very least, some infections go
unnoticed. JAMA. 2022;328(11):1023–1025.
doi: 10.1001/jama.2022.15426. - DOI - PubMed
Waddell CJ FT, Prasad N, et al. Possible
undetected Mpox infection among persons
accessing homeless services and staying in
encampments—San Francisco, California,
October–November 2022. MMWR Morb Mortal
W k l y R e p 2 0 2 3 ; 7 2 : 2 2 7 – 2 3 1 .
15585/mmwr.mm7209a3. - PMC - PubMed
Ogoina D, Dalhat MM, Denue BA, et al.
Nigerian Infectious Diseases Society Mpox
Study Group. Clinical characteristics and
predictors of human Mpox outcome during the
outbreak in Nigeria: a cohort study. Lancet
Infect Dis. 2023;22:S1473-3099(23)00427-9.
doi: 10.1016/S1473-3099(23)00427-9. Epub
ahead of print. PMID: 37625431.
Saldana CS, Kelley CF, Aldred BM, Cantos VD.
Mpox and HIV: a Narrative Review. Curr
HIV/AIDS Rep. 2023;20(4):261-269. doi:
1007/s11904-023-00661-1. Epub 2023 May
PMID: 37178205; PMCID: PMC10182557.
Low N, Bachmann LH, Ogoina D, et al. Mpox
virus and transmission through sexual contact:
Defining the research agenda. PLoS Med. 2023;
0 ( 1 ) : e 1 0 0 4 1 6 3 .
https://doi.org/10.1371/journal.pmed.1004163
Yinka-Ogunleye A, Aruna O, Dalhat M, et.al;
CDC Monkeypox Outbreak Team. Outbreak of
human monkeypox in Nigeria in 2017-18: a
clinical and epidemiological report. Lancet
Infect Dis. 2019;19(8):872-879. doi:
1016/S1473-3099(19)30294-4. Epub 2019
Jul 5. PMID: 31285143; PMCID: PMC9628943.
Rezza G. Emergence of human monkeypox in
West Africa. Lancet Infect Dis. 2019;19(8):797-
doi: 10.1016/S1473-3099(19)30281-6.
Epub 2019 Jul 5. PMID: 31285141.
World He a lth Organi z a tion. (2022).
Monkeypox: Fact sheet. Retrieved from
https://www.who.int/news-room/f a c tsheets/detail/monkeypox.
Mitjà O, Alemany A, Marks M, et al. Mpox in
people with advanced HIV infection: a global
case series [published correction appears in
Lancet. 2023 Apr 8;401(10383):1158]. Lancet.
;401(10380):939-949. doi:10.1016/S0140-
(23)00273-8
Badenoch JB, Conti I, Rengasamy ER, et al.
Neurological and psychiatric presentations
associated with human monkeypox virus
infection: a systematic review and meta-analysis.
EClinicalMedicine. 2022;52:101644.
Sharma R, Nguyen-Luu T, Dhaubhadel P,
Sharma A, Naik R. A Rare Co-occurrence of
Monkeypox Encephalitis and Neurosyphilis.
Cureus. 2023;15(3):e35945. Published 2023 Mar
doi:10.7759/cureus.35945
Ramoni S, Maronese CA, Morini N, et al.
Syphilis and monkeypox co-infection:
Coincidence, synergy or asymptomatic carriage?
Travel Med Infect Dis. 2022;50:102447. doi:
1016/j.tmaid.2022.102447. Epub 2022 Sep 5.
PMID: 36067937; PMCID: PMC9629038.
Bui IT, Sloan B, Tribble M, Moore AY. An HIVpositive man with painless ulcer and pustules:
mpox, syphilis, or both? Proc (Bayl Univ Med
C e n t ) . 2 0 2 3 ; 3 6 ( 4 ) : 5 1 0 - 5 1 3 . d o i:
1080/08998280.2023.2193130. PMID:
; PMCID: PMC10269416.
Mittal R, Pathak M, Jain A. Neuropsychiatric
manifestations of mpox (monkeypox) virus
amidst a global outbreak. Prim Care Companion
CNS Disord. 2022;24(6):22br03429.
Shafaati M, Zandi M. Monkeypox virus
neurological manifestations in comparison to
other orthopoxviruses. Travel Med Infect Dis.
0 2 2 ; 4 9 : 1 0 2 4 1 4 .
doi:10.1016/j.tmaid.2022.102414
Greenlee JE. Nervous System Complications of
Systemic Viral Infections. Aminoff's Neurology
and General Medicine. 2014;857-883.
doi:10.1016/B978-0-12-407710-2.00043-6.
Joy BK, Donovan AL, McCracken GR, et al.
Hunting for Mpox (monkeypox) mimickers: Use
of the Biofire meningitis/encephalitis panel on
lesion swabs to support alternative viral
diagnoses. J Clin Virol. 2023;159:105356.
doi:10.1016/j.jcv.2022.105356
Sepehrinezhad A, Ashayeri Ahmadabad R,
Sahab-Negah S. Monkeypox virus from
neurological complications to neuroinvasive
properties: current status and future perspectives.
J N e u r o l. 2 0 2 3 ; 2 7 0 ( 1 ) : 1 0 1 - 1 0 8 .
doi:10.1007/s00415-022-11339-w
Money KM, Barnett TA, Rapaka S, et al.
Monkeypox-Associated Central Nervous
System Disease: A Case Series and Review. Ann
N e u r o l . 2 0 2 3 ; 9 3 ( 5 ) : 8 9 3 - 9 0 5 .
doi:10.1002/ana.26597
Cole J, Choudry S, Kular S, et al. Monkeypox
encephalitis with transverse myelitis in a female
patient. Lancet infect Dis. 2023;23:e115-20. 10.
/S1473-30999(22) 00749 - 1
Pastula DM, Copeland MJ, Hannan MC et al.
Two cases of monkeypox associated
encephalomyelitis- Colorado and the District of
Res. J. Health Sci. Vol 12(1), March 2024 79
Sokunbi and Adeyemo, 2024
Columbia. 2022 MMWR Morb Mortal. Wkly
Rep. 2022;71:1212-5
Prasad S, Galvan Casas C, Strahan AG, et al. A
dermatologic assessment of 101 mpox
(monkeypox) cases from 13 countries during the
outbreak: Skin lesion morphology, clinical
course, and scarring. J Am Acad Dermatol.
0 2 3 ; 8 8 ( 5 ) : 1 0 6 6 - 1 0 7 3 .
doi:10.1016/j.jaad.2022.12.035
Tagka A, Geronikolou S, Evaggelopoulos A, et
al. Simultaneous Multiple-Stages Mpox Genital
Lesions on the Same Site in a Traveler to Greece:
A Ca s e Re p o rt. Va c c i n e s (Ba s e l).
;11(5):901. Published 2023 Apr 26.
doi:10.3390/vaccines11050901
Pinto-Pulido EL, Fernández-Parrado M,
Rodríguez-Cuadrado FJ. Atypical clinical
features of mpox (monkeypox): a diagnostic
challenge [published online ahead of print, 2023
May 23]. An Bras Dermatol. 2023; S0365-
5 9 6 ( 2 3 ) 0 0 1 1 6 - 2 .
doi:10.1016/j.abd.2023.04.002
Freeman EE, Galvan Casas C, Prasad S, et al. The
American Academy of Dermatology and
International League of Dermatological
Societies Monkeypox Registry: Expanding the
COVID-19 registry to emerging infections. J Am
Acad Dermatol. 2022;87(6):1278-1280.
doi:10.1016/j.jaad.2022.08.053
Tarín-Vicente EJ, Alemany A, Agud-Dios M, et
al. Clinical presentation and virological
assessment of confirmed human monkeypox
virus cases in Spain: a prospective observational
cohort study [published correction appears in
Lancet. 2022 Dec 10;400(10368):2048]. Lancet.
;400(10353):661-669. doi:10.1016/S0140-
(22)01436-2
Angelo KM, Smith T, Camprubí-Ferrer D, et al.
Epidemiological and clinical characteristics of
patients with monkeypox in the GeoSentinel
Network: a cross-sectional study. Lancet Infect
Dis. 2023;23(2):196-206. doi:10.1016/S1473-
(22)00651-X
Beeson A, Styczynski A, Hutson CL, et al. Mpox
respiratory transmission: the state of the
evidence. Lancet Microbe. 2023;4(4):e277-
e283. doi: 10.1016/S2666-5247(23)00034-4.
Epub 2023 Mar 7. PMID: 36898398; PMCID:
PMC9991082.
Ogoina D, Izibewule JH, Ogunleye A, et. Al. The
human monkeypox outbreak in NigeriaReport of outbreak experience and response in
the Niger Delta University Teaching Hospital,
Baye ls a St a t e , Nige ri a . PLoS One .
0 1 9 ; 1 4 ( 4 ) : e 0 2 1 4 2 2 9 . d o i :
1371/journal.pone.0214229. PMID:
; PMCID: PMC6469755.
Learned LA, Reynolds MG, Wassa DW, et al.
Extended interhuman transmission of
monkeypox in a hospital community in the
Republic of the Congo, 2003. Am J Trop Med
Hyg. 2005;73(2):428-434.
McCollum AM, Damon IK. Human Monkeypox.
Clin, Infect Dis. 2014; 58:260-67.
Studemeister L, Pai S, Walsh K, Cooper J. Acute
Tonsillitis Due To Monkeypox. J Emerg Med.
0 2 3 ; 6 4 ( 2 ) : 2 1 1 - 2 1 3 . d o i :
1016/j.jemermed.2022.12.029. Epub 2023
Feb 22. PMID: 36822985; PMCID:
PMC9943563.
Thornhill JP, Barkali S, Walmsley S, et. al.
Monkeypox virus infection in humans accross 16
countries – April – June 2022, N Engl J Med.
; 387: 679-91.
Nolasco S, Vitale F, Geremia A, Tramuto F,
Maida CM, Sciuto A, et al. First case of
monkeypox virus, SARS-CoV-2 and HIV coinfection. J Infect. 2022;S0163-4453(22)00479-
Lai CC, Hsu CK, Yen MY, Lee PI, Ko WC, Hsueh
PR. Monkeypox: An emerging global threat
during the COVID-19 pandemic. J Microbiol
Immunol Infect. 2022;55(5):787-794.
doi:10.1016/j.jmii.2022.07.004
World Health Organization. (2022). Testing for
Monkeypox: Individuals and communities -
Questions and answers. Retrieved from
https://www.who.int/news-room/questions-andanswers/item/testing-for-mpox--individualsand-communities
Waddell CJ FT, Prasad N, et al. Possible
undetected Mpox infection among persons
accessing homeless services and staying in
encampments—San Francisco, California,
October–November 2022. MMWR Morb Mortal
W k l y R e p 2 0 2 3 ; 7 2 : 2 2 7 – 2 3 1 .
15585/mmwr.mm7209a3. - PMC - PubMed
Colton M, Vincent M, Patricia T, Edward L,
Glenn S. P. A 40-Year-Old Man with Anemia,
Proctitis, Rectal Bleeding, and a Perianal Rash
Due to Mpox (Monkeypox) Infection. Am J Case
Rep. 2023; 24: e940177 DOI: 10.12659/AJCR
Reda A, Dhama K. Mpox impact on different
organ systems: Complications, mechanisms, and
management [published online ahead of print,
Mar 30]. Rev Med Virol. 2023;e2443.
doi:10.1002/rmv.2443
Al-Tawfiq JA, Sah R, Altawfiq KJ, Pan Q. Mpoxassociated myopericarditis. New Microbes New
Infect. 2023;51:101085. Published 2023 Jan 18.
doi:10.1016/j.nmni.2023.101085
Huang, Y., Mu, L. & Wang, W. Monkeypox:
epidemiology, pathogenesis, treatment and
prevention. Sig Transduct Target Ther 7, 373
(2022). https://doi.org/10.1038/s41392-022-
-4
Overton ET, Lawrence SJ, Wagner E, et al.
Immunogenicity and safety of three consecutive
production lots of the non-replicating smallpox
vaccine MVA: A randomised, double blind,
placebo controlled phase III trial. PLoS One.
;13(4):e0195897. Published 2018 Apr 13.
doi:10.1371/journal.pone.0195897
Heskin J, Belfield A, Milne C, et al. Transmission
Res. J. Health Sci. Vol 12(1), March 2024 80
Sokunbi and Adeyemo, 2024
of monkeypox virus through sexual contact - A
nove l rout e of inf e c tion. J Inf e c t.
0 2 2 ; 8 5 ( 3 ) : 3 3 4 - 3 6 3 .
doi:10.1016/j.jinf.2022.05.028
Dye C, Kraemer MUG. Investigating the
monkeypox outbreak. BMJ. 2022;377:o1314.
Published 2022 May 26. doi:10.1136/bmj.o1314
Kumar N, Acharya A, Gendelman HE,
Byrareddy SN. The 2022 outbreak and the
pathobiology of the monkeypox virus. J
A u t o i m m u n . 2 0 2 2 ; 1 3 1 : 1 0 2 8 5 5 .
doi:10.1016/j.jaut.2022.102855
Lulli L.G., Baldassarre A., Mucci N., Arcangeli
G. Prevention, Risk Exposure, and Knowledge of
Monkeypox in Occupational Settings: AScoping
Review. Trop. Med. Infect. Dis. 2022;7:276. doi:
3390/tropicalmed7100276
Rizk J.G., Lippi G., Henry B., Forthal D., Rizk Y.
Prevention and treatment of monkeypox. Drugs.
;82:957–963. doi: 10.1007/s40265-022-
-y.
Rao A.K., Petersen B.W., Whitehill F., Razeq
J.H., Isaacs S.N., Merchlinsky M.J., CamposOutcalt D., Morgan R.L., Damon I., Sánchez P.J.,
et al. Use of JYNNEOS (Smallpox and
Monkeypox Vaccine, Live, Nonreplicating) for
Preexposure Vaccination of Persons at Risk for
Occupational Exposure to Orthopoxviruses:
Recommendations of the Advisory Committee
on Immunization Practices—United States 2022.
Morb. Mortal. Wkly. Rep. 2022;71:734. doi:
15585/mmwr.mm7122e1
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Research Journal of Health Sciences
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Research Journal of Health Sciences journal is a peer reviewed, Open Access journal. The Journal subscribed to terms and conditions of Open Access publication. Articles are distributed under the terms of Creative Commons License (CC BY-NC-ND 4.0). (http://creativecommons.org/licences/by-nc-nd/4.0). All articles are made freely accessible for everyone to read, download, copy and distribute as long as appropriate credit is given and the new creations are licensed under the identical terms.