Is acute Myocarditis new manifestation of Monkeypox? -A new case report

A recent case report published in the Journal of the American College of Cardiology reported that acute Myocarditis developed in a patient with Confirmed Monkey Pox virus infection. In the instant case a 31-year-old male with confirmed monkeypox infection developed acute myocarditis approximately one week following the onset of monkeypox symptoms. 

The patient presented to a health clinic five days following the onset of monkeypox symptoms, including malaise, myalgia, fever and multiple swollen lesions on the face, hands and genitalia. Positive monkeypox infection was confirmed with a PCR swab sample of a skin lesion. The patient returned to the emergency department three days later reporting chest tightness radiating through the left arm.

The patient was admitted to an intensive care unit following initial routine examination with the clinical suspicion of acute myocarditis. The initial ECG showed sinus rhythm with nonspecific ventricular repolarization abnormalities and routine laboratory tests revealed elevated levels of C-reactive protein, creatine phosphokinase (CPK), high-sensitivity troponin I and brain natriuretic peptide (BNP), all of which can indicate stress injury to the heart. The results of the cardiac magnetic resonance (CMR) study performed on the patient were consistent with myocardial inflammation and a diagnosis of acute myocarditis.

After the novel, the SARS-COVID-19 infection world is facing another viral infection - The Monkeypox infection. Monkeypox infection is a viral zoonotic infection similar to smallpox. It is caused by a double-stranded DNA virus belonging to the Orthopoxvirus genus of the Poxviridae family. The central African (Congo Basin) clade and the west African clade are the two different genetic clades of this virus. Rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates, and other species are the natural host of this virus. Zoonotic transmission from direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of infected animals and Human-to-human transmission from close contact with respiratory secretions, skin lesions of an infected person, or recently contaminated objects is the main mode of infection spread. 

The incubation period of this infection is 6 to 13 days but can range from 5 to 21 days. Infection occurs in two phases which are the invasion period and the skin eruptions period. The invasion period lasts for 0–5 days and is similar to any other viral infection characterized by fever, intense headache, lymphadenopathy, back pain, myalgia, and intense asthenia. The distinctive feature of monkeypox infection which distinguishes it from other viral infections is Lymphadenopathy. This period is followed by the skin eruption which usually begins 1–3 days after the fever and is generally seen on the face and extremities like the palms of the hands and soles of the feet. Oral mucous membranes, genitalia, conjunctivae, and cornea are the other areas that can have skin eruptions. The evolution of the rash is from macules to papules, vesicles, pustules, and crusts which dry up and fall off and their number varies from a few to several. 

Recently researchers from Portugal reported a case of Monkeypox viral infection in a 31-year-old male patient who subsequently developed acute myocarditis. The myocarditis developed days after the eruption of skin lesions, and it was confirmed by a Cardiac magnetic resonance study. Supportive care was given to the patient as the management. Though the patient recovered completely clinically, this case highlighted the importance of cardiac involvement as a potential complication associated with Monkeypox. 

For the full article, click here: 10.1016/j.jaccas.2022.08.033 

1. Pinho A, Braga M, Vasconcelos M, et al. Acute Myocarditis – a new manifestation of Monkeypox infection?. J Am Coll Cardiol Case Rep. null2022, 0 (0).

2. World Health Organization: WHO. Monkeypox. Who.int. Published May 19, 2022. https://www.who.int/news-room/fact-sheets/detail/monkeypox