Monkey pox

In mid-August 2024, when many of us were on holiday and sightseeing, the World Health Organisation declared monkey pox (mpox) an international public health emergency due to the risks of an outbreak in the Democratic Republic of Congo and other African countries. This is the highest level of alert under international health law, previously only declared for swine flu in 2009, polio in 2014, Ebola in 2013 and then again in 2019, Zika in 2016, Covid in 2020 and the previous mpox outbreak in 2022. 

Monkey pox 

Monkeypox is a serious viral disease, which can also lead to serious eye complications.
It is a 'zoonotic' infection"i.e. transmitted from animals to humans, caused by the monkeypox virus belonging to the 'monkeypox' family.Poxviridae', the same as human smallpox. 
It was originally identified in monkeys in 1958, while the first case in humans dates back to 1970. It is an endemic disease in the rainforest regions of central and western tropical Africa, while the first outbreak outside Africa was recorded in 2003 in the United States and was due to the importation of infected mammals. In 2022, for the first time, many outbreaks were reported in EU Member States and worldwide - in non-endemic countries - that could not be attributed to travel or the importation of mammals. For this reason, between 23 July 2022 and 11 May 2023, the World Health Organisation declared monkey pox an international public health emergency for the first time (PHEIC -Public Emergency of International Concern). 

Symptoms
In humans, monkeypox often manifests itself with a combination of the following symptoms: fever, headache, thrills, fatigue, asthenia, enlarged lymph nodes, back pain, muscle pain. Typically within one to three days after the onset of the fever, skin lesions develop into blisters, pustules and scabs.
The rash occurs in 95% of patients and usually manifests with lesions in the ano-genital areas, trunk, arms, legs, face, palms of the hands and soles of the feet. In 5% of cases the onset manifestation may be lesions in the oro-pharyngeal cavity. 

Diagnosis 

In the presence of symptoms one must, first of all, consult one's general practitioner as soon as possible and take measures of self-isolation with respect to cohabitants, using - where possible - a personal bathroom, as well as not sharing linen and objects. The patient must also avoid contact with any domestic animals, especially mammals. 

The diagnosis of monkeypox is clinical and also makes use of laboratory tests, with nucleic acid amplification tests (PCR, real time PCR), generic for orthopoxvirus (OPXV) and/or, specific for monkeypox virus, performed on DNA extracted from biological samples. 

The contagion 

Animal-to-human contagion occurs through physical contact with infected animals, including rodents and primates, while person-to-person transmission of infection occurs through contact with someone who has a monkeypox rash, through face-to-face, skin-to-skin, mouth-to-mouth or mouth-to-skin contact, including sexual contact. 

Transmission can also occur through contact with contaminated objects, such as clothes, towels, bed linen, electronic devices, surfaces. 

The virus can be transmitted during pregnancy from mother to foetus or after birth through skin-to-skin contact. 

People with monkeypox are infected and contagious, starting from the appearance of prodromal symptoms and until all lesions have turned into scabs and the scabs have fallen off, making way for a new layer of skin underneath. 

Ocular complications 

The mpox virus can affect several vulnerable anatomical sites, including the eyes, which may require special attention and specific therapeutic management. 

Ocular complications of mpox include mild to severe forms of conjunctivitis, blepharitis, keratitis, corneal ulcers and corneal abrasions 

The involvement of the ocular system in monkeypox is an emergency that can severely impair vision and must be managed as a matter of urgency, even though there is very little data on the efficacy of currently available treatments and outcomes of infection. 

If ocular involvement of the mpox virus is suspected, the patient should undergo an ophthalmic examination as soon as possible and ensure constant monitoring of his condition, especially if he presents with vision changes, ocular pain or increasing redness. 

Swabs taken from conjunctival lesions are an appropriate specimen for RT-PCR testing and to confirm both the presence of mpox virus and conjunctival involvement. Extreme caution should be exercised when swabbing, especially if corneal ulcers or very painful lesions are present. 

Slit-lamp examination and fundoscopic exploration may be useful to determine the extent of involvement of anterior (conjunctiva, cornea, iris) or posterior (retina, optic nerve, choroid) ocular structures. 

A patient with suspected or confirmed mpox infection should be kept in a single room with the door firmly closed. In the case of transfers outside the room, the appropriate equipment should be used, including masks and bandages, sheets and gowns to cover wounds. 

Healthcare personnel coming into contact with the patient must wear full protective equipment that includes, in addition to goggles and protective masks, a special respirator equipped with N95 filters or higher.  

Treatment  

The symptoms of monkeypox may resolve spontaneously in 2-4 weeks, without the need for any treatment. If necessary, the patient can be given painkillers and antipyretics. 

In the event of eye complications, systemic antiviral therapy with Tecovirimat (TPOXX), approved by AIFA in March 2022 for the treatment of monkeypox, following the EMA's favourable opinion in January of the same year. 

Precise pharmacokinetic data on penetration levels of the tecovirimat in the ocular surface and deeper structures of the eye.  

The ophthalmologist may also decide to administer topical therapy with trifluridine for conjunctivitis and mpox virus keratitis  

Prevention measures 

In the case of patients diagnosed with mpox to reduce the risk of autoinoculation in the eye, very frequent hand washing is recommended. 

Prophylactic treatment with topical trifluridine may also be adopted in the case of patients with lesions in the eyelids, near the eyes or in very young children who are unable to comply with instructions on hand hygiene and avoiding hand contact with the eyes. 

 On the subject of zoonoses, see also:

• Chikungunya: vaccine on the way - Oculista Italiano
• SOS: bee sting on the eyeball! - Italian Ophthalmologist

• Abdelaal A, Serhan HA, Mahmoud MA, et al. Ophthalmic manifestations of monkeypox virus. Eye (Lond)2022; :7-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/35896700. 

• Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med2022; 387:679-691. 

• V Mazotta, A Mondi, F Carletti, et al. Ocular involvement in monkeypox: Description of an unusual presentation during the current outbreak. J Infect2022; 17:1-3.