PERIANAL AND RECTAL LESIONS IN IMMUNOCOMPROMISED PATIENTS WITH MONKEYPOX: DIAGNOSIS, CLINICAL FEATURES, AND MANAGEMENT IN A TERTIARY CARE HOSPITAL IN MEXICO
Omar Vergara-Fernandez*, Erick A. Ruiz Muñoz, Danilo Tueme de la Peña, Daniel Doniz- Gomez Llanos, Noel Salgado-Nesme
Colorectal Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Ciudad de México, Mexico
The human monkeypox is caused by an orthopoxvirus from the Poxviridae closely related to smallpox. Its name was established in 1958 when the virus was first isolated from monkeys at a research institute in Denmark. The first reported case of human monkeypox was presented in 1970.
Initially the disease was limited to central Africa and countries without a full smallpox vaccination infrastructure, but since May 2022 it started spreading among countries in men who have sex with men (MSM). According to the Central Disease Center (CDC) of the United States, more than 78, 000 cases of human monkeypox have been confirmed. In Mexico, approximately 2,901 cases have been reported. Clinical features vary among patients ranging from flu-like symptoms such as fever, malaise, headache followed by a blistering rash.. We hereby present our first 7 cases of human monkeypox in patients evaluated by the department of Colorectal surgery at a third level hospital in Mexico.
The clinical features, diagnosis and management are discussed. Of the patients presented, all 7 were MSM, with a mean age of 44.5 years, 6 of them had previous diagnosis of HIV, 1 of them had previos diagnosis of Hepatitis C, and all of them had a confirmed diagnosis of human monkeypox by PCR. Patients initial symptoms consisted of fever, malaise, myalgias and arthralgias followed by blisters throughout their upper and lower body, facial and perianal regions. All 7 patients had perianal pain, 2 of them had rectal bleeding, 5 had tenesmus and 1 reported stool narrowing. Physical exam with anoscopy revealed circumferential erythema, friable and hemorrhagic mucosa in the lower rectum, 1 of the patients (14%) had fistula-in-ano. A CT scan was performed as part of their workup, reporting image findings suggestive of proctitis in all patients, and an anorectal abscess in 4 of the 7 patients (57%). Five of seven patients (71%) required hospital admission, and of those, 4 required surgical management (Table 1) and 1 a colonoscopy for evaluation of rectal bleeding. Two patients had severe soft tissue infection that required extensive surgical debridement (Figure 1a, 1b). During their hospital stay 2 patients had a poor evolution, one of them developed atypical pneumonia and the other one acute CNS infection, both resulting in death. The remaining 5 patients had a mean hospital stay of 10.75 days (range 6-15 days). At the 30-day follow up, these 5 patients were asymptomatic, without signs of complications. Anorectal manifestations of human monkeypox may vary widely, it is transmitted by direct intimate contact and presents most commonly in MSM with immunocompromise. The severity of infection may range from anal proctitis presented with perianal pain and tenesmus that resolves spontaneously to perianal sepsis and extensive soft tissue necrosis that could lead to death.
Table 1. Patient characteristics, clinical manifestations, and management
Figure 1a Perianal ulcer with soft tissue necrosis and infection. 1b Perianal ulcer after surgical debridement
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