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Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 556-559
A need to focus on the atypical features and pronounced std transmission of monkey pox and the emergent role of dermatologists in breaking its transmission

Department of Dermatology, Venereology and Leprosy, Dr Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India

Date of Web Publication29-Dec-2022

Correspondence Address:
Kabir Sardana
Department of Dermatology, Venereology and Leprosy, Dr Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_611_22

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How to cite this article:
Sardana K, Sachdeva S, Thole A. A need to focus on the atypical features and pronounced std transmission of monkey pox and the emergent role of dermatologists in breaking its transmission. Indian J Dermatol 2022;67:556-9

How to cite this URL:
Sardana K, Sachdeva S, Thole A. A need to focus on the atypical features and pronounced std transmission of monkey pox and the emergent role of dermatologists in breaking its transmission. Indian J Dermatol [serial online] 2022 [cited 2023 Jun 7];67:556-9. Available from:


From 1 January through 13 November 2022, a cumulative total of 79 411 laboratory-confirmed cases of monkeypox and 50 deaths have been reported to WHO from 110 countries. In India, 17 cases have been reported and it is pertinent to focus on the atypical manifestations of the present epidemic, especially the marked preponderance in men-who-have-sex-with-men (MSM) that highlights the role of sexual transmission and early diagnosis, with the possibility of a STD link that may have been overlooked.

We carried out a PubMed search with the key words [Monkey Pox, Transmission, Sexually transmitted Disease, Prevention]. A summary of data showed that in the majority of cases,[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] there was a notable history of sexual transmission [Table 1]. The data that has been listed in [Table 1] clearly show that apart from close contact, there is a definite link with HIV and MSM behaviour, and thus monkepox could possibly be a STD. A recent study showed that 56 of 197 cases (31.5%) screened had a concomitant sexually transmitted infection and 196 were identified as gay, bisexual, or other men who had sex with men. All presented with mucocutaneous lesions, most commonly on the genitals (n = 111 participants, 56.3%) or the perianal area (n = 82, 41.6%).[1] This highlights the fact that in many of the cases, there are genital lesions, and almost half (47.2%) of the cohort had systemic symptoms after rather than preceding the onset of lesions.[1] The eruption can mimic herpes genitalis, and thus dermatologists adequately trained in diagnosing STDs can diagnose such cases early.[12] The pronounced and exclusive genital involvement can precede the classic cutaneous manifestations which again reiterates the role of dermatologists.[13]
Table 1: Review of literature on recent reported studies on monkey pox from around the world*

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A recent paper analysed six clusters in Europe and UK and noted that the most common sex affected were males.[14] A notable aspect was that sexual transmission was believed to be a likely cause. The clinical presentation was atypical and unusual, characterized by anogenital lesions and rashes that relatively spare the face and extremities. The symptoms noted were fever (in 54.29% of cases), inguinal lymphadenopathy (45.71%), and exanthema (40.00%). Asthenia, and fatigue and headache were described in 22.86% and 25.71% of the subjects, respectively. Myalgia was present in 17.14% of the cases. Most relevant was the finding that both genital and anal lesions (ulcers and vesicles) were reported in 31.43% of the cases. A recent WHO situation report stated that with the exception of countries in the African region, the ongoing outbreak of monkeypox continues to primarily affect men who identify as gay, bisexual, and other men who have sex with men, and who have reported recent sex with one or multiple partners [Box 1]. The most commonly source was in a party setting with sexual contact. While cases are being reported among other men as well as among women and children, the trends do not suggest that the that transmission in these new groups is sustained.

Thus the present data identifies risk factors that are predictive of monkey pox that include being a young male, having sex with other men, engaging in risky behaviours and activities including condomless sex, human immunodeficiency virus (HIV) positivity, and a history of previous or concomitant sexually transmitted infections.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11]

There have been some peculiarities of the present epidemic that highlight the importance of dermatologists in diagnosing the disorder [Table 1] and [Table 2]. First is the pronounced penile swelling and rectal pain, which also accounts for the hospital admission. Severity of symptoms do not always correlate with a high lesion burden or typical patterns of cutaneous manifestations. Also, in most cases the systemic symptoms are seen after systemic the onset of lesions. This is contrary to guidelines that require typical systemic symptoms to be present in addition to cutaneous lesions. This again highlights the role of dermatologists in early diagnosis of the infection. The marked preponderance of lesions in the genital, perianal, and perioral or tonsillar areas with the history of recent sexual contact suggests that the lesions may initially form at the site of inoculation, followed by the development of systemic symptoms and subsequent dissemination of lesions. A notable aspect is that 35.5% of cases had a polymorphic rash with maculopapular rashes that did not become pustular or ulcerated.
Table 2: Comparison of features of the present as opposed to previous epidemics

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It is abundantly clear that the symptomology necessitates dermatologists to be made part of the referral strategy [Figure 1] and [Figure 2], and dermatologists can be primed for suspecting monkey pox in cases with suggestive genital lesions [Figure 3]. An option is to administer the high-risk population with the approved vaccines. While this is being practised in other countries the same is not possible at the present in India.[15]
Figure 1: Discrete umbilicated vesicle present on the lateral aspect of forehead

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Figure 2: Discrete papulovesicles present on the left palm

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Figure 3: Discrete ulcer present on the coronal sulcus of the penis

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It is pertinent to reiterate that the present active interventions for the disease are either vaccines (JYNNEOSTM live, replication incompetent vaccinia virus and ACAM2000® live, replication competent vaccinia virus) or certain antivirals (e.g. tecovirimat, brincidofovir, cidofovir) and vaccinia immune globulin intravenous (VIGIV). In most cases, supportive treatments are enough to tide over the infection.[1]

The present data does suggest that the infection is generally a self-limiting disease with a low fatality rate. There are cases without any history of contact which suggests that there is either asymptomatic or pauci-symptomatic transmission. Antivirals (e.g. tecovirimat, brincidofovir, cidofovir) and VIGIV are available as treatments, but they are restricted to severe disease, immunocompromised patients, paediatric cases, pregnant and breastfeeding women, complicated lesions, and when lesions appear near the mouth, eyes, and genitals.[16] Dermatologists should be on the forefront to nip the transmission of the disease and we need to synchronise our efforts to focus on the genital manifestations and the likely STD transmission of monkey pox, thus breaking a possible route of transmission [Box 2].

Informed consent

The patients have given written, informed consent for the publication of their case images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Patel A, Bilinska J, Tam JCH, Da Silva Fontoura D, Mason CY, Daunt A, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: Descriptive case series. BMJ 2022;378:e072410.  Back to cited text no. 1
Noe S, Zange S, Seilmaier M, Antwerpen MH, Fenzl T, Schneider J, et al. Clinical and virological features of first human monkeypox cases in Germany. Infection 2022:1-6. doi: 10.1007/s15010-022-01874-z.  Back to cited text no. 2
Heskin J, Belfield A, Milne C, Brown N, Walters Y, Scott C, et al. Transmission of monkeypox virus through sexual contact-A novel route of infection. J Infect 2022. doi: 10.1016/j.jinf. 2022.05.028.  Back to cited text no. 3
Girometti N, Byrne R, Bracchi M, Heskin J, McOwan A, Tittle V, 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;22:1321-8.  Back to cited text no. 4
Antinori A, Mazzotta V, Vita S, Carletti F, Tacconi D, Lapini LE, et al. Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022. Euro Surveill 2022;27:2200421. doi: 10.2807/1560-7917.ES.2022.27.22.2200421.  Back to cited text no. 5
Perez Duque M, Ribeiro S, Martins JV, Casaca P, Leite PP, Tavares M, et al. Ongoing monkeypox virus outbreak, Portugal, 29 April to 23 May 2022. Euro Surveill 2022;27:2200424. doi: 10.2807/1560-7917.ES.2022.27.22.2200424.  Back to cited text no. 6
Selb R, Werber D, Falkenhorst G, Steffen G, Lachmann R, Ruscher C, et al. A shift from travel-associated cases to autochthonous transmission with Berlin as epicentre of the monkeypox outbreak in Germany, May to June 2022. Euro Surveill 2022;27:2200499. doi: 10.2807/1560-7917.ES.2022.27.27.2200499.  Back to cited text no. 7
Orviz E, Negredo A, Ayerdi O, Vázquez A, Muñoz-Gomez A, Monzón S, et al. Monkeypox outbreak in Madrid (Spain): Clinical and virological aspects. J Infect 2022. doi: 10.1016/j.jinf. 2022.07.005.  Back to cited text no. 8
Iñigo Martínez J, Gil Montalbán E, Jiménez Bueno S, Martín Martínez F, Nieto Juliá A, Sánchez Díaz J, et al. Monkeypox outbreak predominantly affecting men who have sex with men, Madrid, Spain, 26 April to 16 June 2022. Euro Surveill 2022;27:2200471. doi: 10.2807/1560-7917.ES.2022.27.27.2200471.  Back to cited text no. 9
Patrocinio-Jesus R, Peruzzu F. Monkeypox genital lesions. N Engl J Med 2022;387:66.  Back to cited text no. 10
Basgoz N, Brown CM, Smole SC, Madoff LC, Biddinger PD, Baugh JJ, et al. Case 24-2022: A 31-year-old man with perianal and penile ulcers, rectal pain, and rash. N Engl J Med 2022;387:547-56.  Back to cited text no. 11
Davido B, D'anglejan E, Jourdan J, Robinault A, Davido G. Monkeypox2022 outbreak: Cases with exclusive genital lesions. J Travel Med 2022:taac077. doi: 10.1093/jtm/taac077.  Back to cited text no. 12
Hammerschlag Y, MacLeod G, Papadakis G, Adan Sanchez A, Druce J, Taiaroa G, et al. Monkeypox infection presenting as genital rash, Australia, May 2022. Euro Surveill 2022;27:2200411.  Back to cited text no. 13
Bragazzi NL, Kong JD, Mahroum N, Tsigalou C, Khamisy-Farah R, Converti M, et al. Epidemiological trends and clinical features of the ongoing monkeypox epidemic: A preliminary pooled data analysis and literature review. J Med Virol 2022. doi: 10.1002/jmv. 27931.  Back to cited text no. 14
Petersen E, Zumla A, Hui DS, Blumberg L, Valdoleiros SR, Amao L, et al. Vaccination for monkeypox prevention in persons with high-risk sexual behaviours to control on-going outbreak of monkeypox virus clade 3. Int J Infect Dis 2022;122:569-71.  Back to cited text no. 15
Guidelines for Management of Monkeypox Disease. Ministry of Health and Family Welfare. Government of India. Avaialble from: [Last accessed on 2022 Jul 25].  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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