Thread by @profchloeorkin

📢 Published today in @NEJM to aid #monkeypox diagnosis:

A global collaborative case series led by @ShareEastLondon @QMUL describing 528 confirmed infections from 43 centres in 16 countries + an image library.

@rcgp @RCPhysicians

bit.ly/3PGg7js @JohnPThornhill🧵

2/Before April 2022, MPXV in humans was seldom reported outside African regions where it is endemic. Currently, cases are occurring globally. Transmission, risk factors, clinical presentation & outcomes of infection are poorly defined. MPXV research has been grossly underfunded

3/We formed an international collaborative group of clinicians who contributed to the global case series to describe the presentation, clinical course, and outcomes of PCR–confirmed monkeypox virus infections. @IAS @HIVpxresearch

4/Overall, 98% of the people we describe with MPXV infection were GBMSM, 75% were White, and 41% were PWH, the median age was 38 years. Transmission was suspected to have occurred through sexual closeness in 95% of people. @BASHH_UK @aidsmap

5/Symptoms: 95% of people presented with a rash (64% had <10 lesions), 73% had anogenital lesions. 41% had mucosal lesions and ~10% had a single genital lesion. Single lesions are easily confused with STI’s @BASHH @BritishHIVAssoc

6/ Ano-rectal involvement as the first symptom was reported in 61 ppl (>10%) associated with severe anorectal pain, proctitis, tenesmus and/or diarrhoea.  Ano-rectal symptoms sometimes led to admission for pain control. @CarlosdelRio7 @mugecevik

7/ Oropharyngeal symptoms were the initial presentation reported in 26 individuals with pharyngitis, painful swallowing, epiglottitis, and oral or tonsillar lesions. Some required hospitalisation. Conjunctival mucosa & nasal lesions occurred. @RCollEM @karimbrohi

8/ Common systemic features preceding the rash included: fever (62%), lethargy (41%), myalgia (31%), headache (27%) lymphadenopathy(56%).@rcgp @rcgp @RCollEM

9/ Concomitant STIs and incubation period:  STI’swere reported in 109 / 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).@BASHH_UK @BritishHIVAssoc

10/ HIV: 41% of people included were PWH. Outcomes were no different than in people without HIV. This is reassuring. Almost all PWH were undetectable; Median CD4 count  >600. We can’t comment on severity in immunosuppressed PWH @drlaurawaters @BritishHIVAssoc @EACSociety

11/ Testing: Semen pcr testing took place at several centres. Monkeypox virus DNA was detected in 29 of the 32 persons in whom seminal fluid was analysed. We don’t know if the virus is transmissible in semen. @BASHH_UK @andreaantinori

12/Antiviral treatment was given to 5%.
70 (13%) were hospitalised- mainly for pain management: rectal pain (21); soft-tissue superinfection(18); pharyngitis (5); eye lesions (2); acute kidney injury (2); myocarditis (2). 13 were for infection control ,no deaths @RCPhysicians

13/ Smallpox vaccination and age: 9% reported having had a smallpox vaccine previously  and 56 people were > age of 50. @mugecevik

14/ We found a wide variety of dermatologic, mucosal & systemic clinical presentations .We depicted this in an extensive image library with> 20 clinical presentations.  Doctors need to rapidly identify & diagnose MPXV to contain further spread.@RCPhysicians @rcgp @iasociety

15/ International case definitions don’t focus on purely mucosal first presentations. These happened frequently and accounted for some of the worst disease severity and at times necessitated admission. We call for expanded case definitions @WHO @EACSociety @UKHSA.

16/ Without an equitably available vaccine or anti-viral treatment for this neglected underfunded disease, accurate case definition is a key public health tool to contain the global outbreaks. We hope our work will help doctors & HCPS to do this more easily.@iasociety @WHO

17/ Huge thanks go both to the people with MPXV infection across the world who generously gave their permission for us to learn from their experiences and to the > 100 doctors and HCPS who worked so hard to care for them and to collect the data so very quickly 🙏🏽🙏🏽 @NHSEngland

18/
I will take away two very important learnings about interconnectedness:
Viruses know no borders
New friendships amongst the global collaborator group also know no borders.
Hope to see some of you at #AIDS2022 @iasociety