Clinical Presentation (References)

4 August 2022

Moschese D, Giacomelli A, Beltrami M, et al. Hospitalisation for monkeypox in Milan, Italy. Travel Med Infect Dis. 2022 Aug 4:102417. PubMed: Full text:

The hospitalisation rate observed in Milan, Italy was 8.8%. Bacterial superinfection and severe perianal pain were the main cause of hospitalisation requiring antibiotic treatment and analgesic therapy.


31 July 2022

Hoffmann C, Jessen H, Boesecke C. Monkeypox in Germany-Initial Clinical Observations. Dtsch Arztebl Int. 2022 Aug 12;(Forthcoming):arztebl.m2022.0287. PubMed: Full text:

Study from Germany. A total of 301 PCR-confirmed cases from 32 centres were recorded up to 23 June 2022. Only MSM were affected, including 141 (46.7%) with HIV infection and 135 (44.7%) with pre-exposure prophylaxis (PrEP). The vast majority of smallpox lesions were anal or genital. The most common general symptoms were fever, headache, pain in the limbs and often painful swelling of the lymph nodes. Most illnesses so far have been relatively mild, but hospitalisation occurred in 5.0%. No deaths were observed. The high number of sexually transmitted infections (STI) was striking. Only 41.0 % had not been diagnosed with an STI in the last six months before the MPXV infection.


29 Jul 2022

Benatti SV, Venturelli S, Comi N, Borghi F, Paolucci S, Baldanti F. Ophthalmic manifestation of monkeypox infection. Lancet Infect Dis. 2022 Jul 29:S1473-3099(22)00504-7. PubMed: Full text:

“During the ongoing monkeypox outbreak, monkeypox should be included in the differential diagnosis of patients with vesicular and pustular eye lesions, especially in the presence of epidemiological links or risk factors.”


28 July 2022

Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul 28;378:e072410. PubMed: Full text:

Report on 197 patients with PCR-confirmed monkeypox infection (all men, median age: 38 years). All patients presented with mucocutaneous lesions, most commonly on the genitals (56.3%) or in the perianal area (41.6%). 86.3% of the patients reported systemic illness. The most common systemic symptoms were fever (61.9%), lymphadenopathy (57.9%), and myalgia (31.5%). 61.5% of the patients developed systemic features before the onset of mucocutaneous manifestations. 13.7% presented exclusively with mucocutaneous manifestations without systemic features. 36.0% reported rectal pain, 16.8% sore throat, and 15.7% penile oedema. 13.7% had oral lesions and 4.6% had tonsillar signs. 35.9% of the participants had concomitant HIV infection. 56 (31.5%) of those screened for sexually transmitted infections had a concomitant sexually transmitted infection. Overall, 10.2% of the participants were admitted to hospital for the management of symptoms, most commonly rectal pain and penile swelling.


27 July 2022

Abdelaal A, Serhan HA, Mahmoud MA, Rodriguez-Morales AJ, Sah R. Ophthalmic manifestations of monkeypox virus. Eye (Lond). 2022 Jul 27. PubMed: Full text:

A brief discussion of ophthalmic manifestations of monkeypox infection before the current epidemic. Corneal involvement could range from mild to severe. “Photophobia, alone, was reported in approximately 22% of affected patients. In addition, severe corneal infections that can result in severe keratitis forms (seen in 7.5% of patients in one study), corneal scarring (seen in 4% of unvaccinated, and 1% of previously smallpox-vaccinated case patients), and permanent vision loss were also reported. One study found unilateral or bilateral blindness, and weak vision in 10% of primary and 5% of secondary cases.” In another study, blepharitis was observed in 30% of unvaccinated, and in 7% of previously smallpox-vaccinated patients.


21 July 2022

Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries – April-June 2022. N Engl J Med. 2022 Jul 21. PubMed: Full text:

The authors report 528 infections diagnosed between April 27 and June 24, 2022. 98% of the persons with infection were gay or bisexual men, 41% had HIV infection (median age was 38 years). “95% of the persons presented with a rash (with 64% having <10 lesions), 73% had anogenital lesions, and 41% had mucosal lesions (with 54 having a single genital lesion). Common systemic features preceding the rash included fever (62%), lethargy (41%), myalgia (31%), and headache (27%); lymphadenopathy was also common (reported in 56%). Concomitant sexually transmitted infections were reported in 109 of 377 persons (29%) who were tested. Among the 23 persons with a clear exposure history, the median incubation period was 7 days (range, 3 to 20). Monkeypox virus DNA was detected in 29 of the 32 persons in whom seminal fluid was analyzed.” 70 patients (13%) were hospitalized, mainly for severe anorectal pain (21 persons); soft-tissue superinfection (18); pharyngitis limiting oral intake (5); eye lesions (2); acute kidney injury (2); myocarditis (2); and infection-control purposes (13). No deaths.


13 July 2022

Rodríguez BS, Herrador BRG, Franco AD, et al. Epidemiologic Features and Control Measures during Monkeypox Outbreak, Spain, June 2022. Emerg Infect Dis. 2022 Jul 12;28(9). PubMed: Full text:

The authors provide epidemiologic features of 1256 cases (1,242 cases were in men and 14 in women)  reported in Spain and the coordinated measures taken to respond to this outbreak. Among 45 patients who self-referred a clear exposure date the average incubation period was 7‒9.6 days. The most frequent symptoms reported (n = 530) were rash (mainly anogenital), fever, asthenia, and lymphadenopathy. Of the 216 case-patients who had localized lymphadenopathy, 191 had general symptoms. A total of 30 of the 530 case-patients were hospitalized (median admission 2 days); 33 reported complications, mainly secondary bacterial infections (n = 15) oral ulcers (n = 11), proctitis (n = 2), and pharyngotonsillitis (n = 2). No deaths were reported.


10 July 2022

Orviz E, Negredo A, Ayerdi O, et al. Monkeypox outbreak in Madrid (Spain): clinical and virological aspects. J Infect. 2022 Jul 10:S0163-4453(22)00415-7. PubMed: Full text:

The median age (n=48) was 35 years (IQR 29 – 44), and 87.5% were MSM. The most prevalent symptoms were the presence of vesicular-umbilicated and pseudo-pustular skin lesions (93.8%), asthenia (66.6%), and fever (52.1%). In addition, the location of the lesions in the genital or perianal area was related to the role in sexual intercourse (p<0.001).


1 July 2022

Girometti N, Byrne R, Bracchi M, et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. Lancet Infect Dis. 2022 Jul 1:S1473-3099(22)00411-X. PubMed: Full text:

Can monkeypox be transmitted through local inoculation during close skin-to-skin or mucosal contact, during sexual activity? The author’s preliminary answer would be “Yes”. Here, they describe the clinical characteristics of 54 individuals, all identifying as men who have sex with men (MSM), of whom 13 (24%) were living with HIV. 36 (67%) of patients reported fatigue or lethargy, 31 (57%) reported fever, 10 (18%) had no prodromal symptoms, and 30 (55%) had lymphadenopathy. All patients presented with skin lesions, of which 51 (94%) were anogenital. 37 (89%) of 54 individuals had skin lesions affecting more than one anatomical site and four (7%) had oropharyngeal lesions. Around 25% had a concurrent sexually transmitted infection (STI). Five (9%) of 54 individuals required hospitalization. There were no deaths.


10 June 2022

Minhaj FS, Ogale YP, Whitehill F, et al. Monkeypox Outbreak – Nine States, May 2022. MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):764-769. PubMed: Full text:

“Monkeypox virus is spread through close, often sustained skin-to-skin contact, but the initial appearance or occurrence of lesions in the anogenital area observed in the current outbreak differs from the typical appearance or occurrence beginning on the face, oral mucosa, and hands and feet, then spreading to other parts of the body in a centrifugal distribution.”


7 June 2022

Antinori A, Mazzotta V, Vita S, et al. Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022. Euro Surveill. 2022 Jun;27(22):2200421. PubMed: Full text:

The authors describe the first four monkeypox cases in Italy. “…the clinical picture seems to be different from the available information in the literature because the skin lesions in our patients were asynchronous, ranging from single or clustered spot to umbilicated papule with progressive central ulceration and, finally, to scabs. Lesions were mostly located in genital and perianal sites.”


24 May 2022

Adler H, Gould S, Hine P, et al. Clinical features and management of human monkeypox: a retrospective observational study in the UK. Lancet Infect Dis. 2022 May 24:S1473-3099(22)00228-6. PubMed: Full text:

In this retrospective study, the authors report the clinical features, longitudinal virological findings, and response to off-label antivirals in 7 patients with monkeypox who were diagnosed in the UK between 2018 and 2021. Notable aspects include the first nosocomial and household transmissions to be reported outside of the African continent, surprisingly long durations of viral DNA shedding, and the use of novel direct-acting antivirals.


16 November 2018

Petersen E, Abubakar I, Ihekweazu C, et al. Monkeypox – Enhancing public health preparedness for an emerging lethal human zoonotic epidemic threat in the wake of the smallpox post-eradication era. Int J Infect Dis. 2019 Jan;78:78-84. PubMed: Full text:

Considerations about the 2018 monkeypox outbreack in Nigeria (> 100 cases, median age of the cases are 31 years, almost all belonging to an age group that was not vaccinated against smallpox). The authors find an approximately 20-fold increase in monkeypox incidence compared to the historic data upto 1986 has occurred in and West Africa. There were also differences in skin and mucosal lesions in patients with previous smallpox vaccination as defined by presence of vaccination scar, compared to those patients who were not vaccinated. In vaccinated individuals the skin rashes and vesicles appear less intense, milder and more pleomorphic, and fewer in comparison with those unvaccinated individuals.


22 January 2004

Reed KD, Melski JW, Graham MB, et al. The detection of monkeypox in humans in the Western Hemisphere. N Engl J Med. 2004 Jan 22;350(4):342-50. PubMed: Full text:

Description of the 11 initial cases of the 2003 outbreak in the United States, five males and six females ranging in age from 3 to 43 years.