Important differences in monkeypox symptoms between the current outbreak and previous outbreaks in endemic regions have been identified.
The findings, based on 197 confirmed monkeypox cases at an infectious disease centre in London between May and July 2022, show that some common symptoms, including rectal pain and penile swelling, differ from those described in previous outbreaks.
The researchers from Guys and St Thomas’ NHS Foundation Trust recommend that clinicians consider monkeypox infection in patients presenting with these symptoms, adding those with confirmed monkeypox infection with extensive penile lesions or severe rectal pain “should be considered for ongoing review or inpatient management”.
According to government data, at 18 July 2022, there were 2,137 confirmed cases of monkeypox in the UK, of which 2,050 were in England – 73% of which were in London.
All 197 participants in this study were men, whose average is age 38 years. All but one said they identified as gay, bisexual, or other men who have sex with men.
Writing in *The BMJ*, they research team say all patients presented with lesions on their skin or mucosal membranes, most commonly on the genitals or in the perianal area and 86% reported systemic illness. The most common systemic symptoms were fever (62%), swollen lymph nodes (58%), and muscle aches and pain (32%).
And while existing case reports suggested that systemic symptoms precede skin lesions, 38% of patients developed systemic symptoms after the onset of mucocutaneous lesions, while 14% presented with lesions without systemic features.
Out of the 197, 71 reported rectal pain, 33 a sore throat, and 31 penile oedema, while 27 had oral lesions, 22 had a solitary lesion, and nine had swollen tonsils.
Solitary lesions and swollen tonsils were not previously known to be typical features of monkeypox infection and could be mistaken for other conditions, say the researchers.
Just over a third (36%) of participants also had HIV infection and 32% of those screened for sexually transmitted infections had a sexually transmitted infection.
Twenty (10%) of the participants were admitted to hospital to manage their symptoms, which were most commonly rectal pain and penile swelling. No deaths were reported and no patients required intensive hospital care.
Only one participant had recently travelled to an endemic region, which confirms ongoing transmission within the UK, and a quarter of patients had known contact with someone with confirmed monkeypox infection, raising the possibility of transmission by people with no or very few symptoms.
Although the authors acknowledge some limitations to their study, they say their findings confirm the ongoing unprecedented community transmission of monkeypox virus among gay, bisexual, and other men who have sex with men seen in the UK and many other non-endemic countries.
“Understanding these findings will have major implications for contact tracing, public health advice, and ongoing infection control and isolation measures,” they write.
They have also called for continued research to inform infection control and isolation policies and guide the development of new diagnostics, treatments, and preventive measures.
Patel A, Bilinska J, Tam JCH et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. *The BMJ*. July 2022. doi: 10.1136/bmj 2022-072410
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