Ocular manifestation of Monkeypox infection: JAMA Ophthalmology

His visual acuity was 6/6 in both eyes. Examination of his right eye revealed erythematous swollen eyelids. A slightly raised dome shaped umbilicated nodule, of approximately 3 mm, was present on his medial one-third lower eyelid margin, with a similar lesion developing on the corresponding upper eyelid margin.

A vesicular lesion was also present on the caruncle and there was global conjunctival hyperemia, mostly pronounced nasally and around the lesions. There were no signs of corneal involvement, and the anterior chamber was quiet. The left eye was normal.

Results of fundus examination in both eyes were normal. No preauricular or submandibular lymph node involvement was noted, but cervical lymph nodes were enlarged. The pharynx was erythematous and swollen with white pus patches.

The skin lesions were dome-shaped papules, round, pinkish-white in color, surrounded by an erythematous area. Full blood cell count and tests for HIV, AIDS, and syphilis were ordered. Conjunctival swabs and eyelid vesicle fluid were taken for polymerase chain reaction testing. Swabs of the upper respiratory tract were also taken.

Patient was diagnosed having Ocular manifestation of Monkeypox infection. Patient was isolated and public health authorities were notified.

HMPX is a zoonosis caused by infection with the Monkeypox virus, an Orthopoxyvirus of the Poxvyridae family. The disease was first described in central Africa in 1970 and has historically affected some of the poorest communities in the world, being rarely exported from the African continent. Commonly reported clinical features include fever, headache, muscle aches, backache, swollen lymph nodes, chills, exhaustion, and a skin rash, characterized by pimple or blister like lesions that appear on the face, hands, feet, chest, genitals, or anus. The illness typically lasts 2 to 4 weeks. Complications include pneumonia, encephalitis, and secondary bacterial infections.

The present case may represent a case of eyelid and conjunctival involvement during the HMPX outbreak. Although no serologic testing was performed, the eyelid swab and vesicle fluid were PCR positive for orthopoxvirus and monkeypox DNA. Our finding suggests that, in the presence of an eyelid nodule with conjunctival inflammation, the diagnosis of HMPX should be considered and public health authorities should be alerted. A systemic workup is warranted to exclude systemic involvement of the disease.

Currently, there are no licensed treatments for human monkeypox. Two drugs, brincidofovir and tecovirimat, have demonstrated efficacy against orthopoxviruses, including monkeypox, in animal models and may be used to treat HMPX infections, especially in patients with severe symptoms and immunocompromised immune system.

The reported prognosis of HMPX varies substantially and is vulnerable to case ascertainment bias. The case fatality ratio has historically ranged from 3% to 10% and has been higher among young children and immunocompromised individuals. In recent times, the case fatality ratio has been around 3% to 6%.

Vaccines used during the smallpox eradication program also provided protection against monkeypox. Newer vaccines have been developed, of which one has been approved for prevention of monkeypox. Health care professionals should be aware that patients presenting with conjunctivitis and eyelid lesions might be infected by monkeypox virus.

The patient was admitted in isolation. A treatment with oral tecovirimat (600 mg twice daily) was prescribed with remarkable improvement of the ocular and skin conditions within 10 days.

Source: Georgios Kontos, MD; Eleonora Micheletti, MD; JAMA Ophthalmology Clinical Challenge

doi:10.1001/jamaophthalmol.2022.3741