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Clinical features and management of human monkeypox: a retrospective observational study in the UK

Adler, Hugh ORCID: https://orcid.org/0000-0003-4437-2298, Gould, Susan, Hine, Paul, Snell, Luke B, Wong, Waison, Houlihan, Catherine F, Osborne, Jane C, Rampling, Tommy, Beadsworth, Mike, Duncan, Christopher JA, Dunning, Jake, Fletcher, Tom, Hunter, Ewan R, Jacobs, Michael, Khoo, Saye K, Newsholme, William, Porter, David, Porter, Robert J, Ratcliffe, Libuše, Schmid, Matthias, Semple, Malcolm G, Tunbridge, Anne J, Wingfield, Tom ORCID: https://orcid.org/0000-0001-8433-6887 and Price, Nicholas M (2022) 'Clinical features and management of human monkeypox: a retrospective observational study in the UK'. Lancet Infectious Diseases. (In Press)

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Abstract

Background
Cases of human monkeypox are rarely seen outside of west and central Africa. There are few data regarding viral kinetics or the duration of viral shedding and no licensed treatments. Two oral drugs, brincidofovir and tecovirimat, have been approved for treatment of smallpox and have demonstrated efficacy against monkeypox in animals. Our aim was to describe the longitudinal clinical course of monkeypox in a high-income setting, coupled with viral dynamics, and any adverse events related to novel antiviral therapies.

Methods
In this retrospective observational study, we report the clinical features, longitudinal virological findings, and response to off-label antivirals in seven patients with monkeypox who were diagnosed in the UK between 2018 and 2021, identified through retrospective case-note review. This study included all patients who were managed in dedicated high consequence infectious diseases (HCID) centres in Liverpool, London, and Newcastle, coordinated via a national HCID network.

Findings
We reviewed all cases since the inception of the HCID (airborne) network between Aug 15, 2018, and Sept 10, 2021, identifying seven patients. Of the seven patients, four were men and three were women. Three acquired monkeypox in the UK: one patient was a health-care worker who acquired the virus nosocomially, and one patient who acquired the virus abroad transmitted it to an adult and child within their household cluster. Notable disease features included viraemia, prolonged monkeypox virus DNA detection in upper respiratory tract swabs, reactive low mood, and one patient had a monkeypox virus PCR-positive deep tissue abscess. Five patients spent more than 3 weeks (range 22–39 days) in isolation due to prolonged PCR positivity. Three patients were treated with brincidofovir (200 mg once a week orally), all of whom developed elevated liver enzymes resulting in cessation of therapy. One patient was treated with tecovirimat (600 mg twice daily for 2 weeks orally), experienced no adverse effects, and had a shorter duration of viral shedding and illness (10 days hospitalisation) compared with the other six patients. One patient experienced a mild relapse 6 weeks after hospital discharge.

Interpretation
Human monkeypox poses unique challenges, even to well resourced health-care systems with HCID networks. Prolonged upper respiratory tract viral DNA shedding after skin lesion resolution challenged current infection prevention and control guidance. There is an urgent need for prospective studies of antivirals for this disease.

Item Type: Article
Subjects: QW Microbiology and Immunology > Viruses > QW 160 Viruses (General). Virology
WA Public Health > WA 20.5 Research (General)
WC Communicable Diseases > WC 20 Research (General)
WC Communicable Diseases > Virus Diseases > Infectious Viral Skin Diseases > WC 584 Poxviridae infections
Faculty: Department: Clinical Sciences & International Health > Clinical Sciences Department
Digital Object Identifer (DOI): https://doi.org/10.1016/S1473-3099(22)00228-6
Depositing User: Christianne Esparza
Date Deposited: 09 Jun 2022 10:58
Last Modified: 09 Jun 2022 10:58
URI: https://archive.lstmed.ac.uk/id/eprint/20548

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