No skin lesions? You could still have Monkeypox. Watch out for hidden signs with nose, throat and urine tests, says ICMR-NIV

If we thought that Monkeypox had specific markers for diagnosis, think again. Experts around the world are saying that increasing atypical symptoms have meant that the virus is going completely undetected or being maken for a sexually transmitted disease (STD). Now a new study the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV) researchers, who reported the first fatal case of Monkeypox (MPXV) from India, also highlights the importance of maintaining a high index of suspicion for diagnosis and looking for hidden signs. In fact, they have suggested a comprehensive testing of nose, throat and possibly urine specimens as critical for MPXV diagnosis in cases where there are no skin lesions.
In the most extensive report on Monkeypox carried out to date, the ICMR study indicates that the infection can frequently present itself with atypical symptoms and complications compared to previous epidemics or cases in endemic areas. The researchers emphasise that this should be taken into account medical professionals when diagnosing suspected cases, particularly in areas of high transmission or potential exposure. According to the researchers, who presented study findings in Research Square on September 13, “a fatal case of monkeypox virus infection from Kerala, India 2022”, as a pre-print that has not been peer reviewed, illustrates why a close watch should be maintained for diagnosing MPXV in those presenting with atypical manifestations and fever with epidemiological linkage from MPXV-endemic or outbreak countries.

Till date, India has recorded 11 cases of Monkeypox infection from Kerala (n = 5) and New Delhi (n = 6). Dr Sujeet Singh, Director of National Centre for Disease Control, says more than 300 suspected samples have been tested for MPXV and ruled out for the infection.
The World Health Organisation (WHO) reports indicate over 52,000 people have been infected with MPXV while a total of 15 fatalities have been reported globally from endemic and non-endemic countries in 2022. The mortality in Brazil and Mexico were primarily in immuno-compromised individuals, while in Spain the fatal cases were immuno-competent with no underlying conditions.
The current outbreak of Monkeypox had been largely limited to the community of men who have sex with men primarily with multiple bisexual or homosexual partners. The vast majority of the cases infected with Monkeypox had recovered and the complications like sepsis and encephalitis had been reported in the immuno-compromised individuals.
The first fatal case of Monkeypox virus (MPXV) infection imported from UAE to Kerala was reported in July this year. According to researchers, the 22-year-old apparently immuno-competent male with no significant past medical hory was admitted in an unconscious state to a private hospital in Kerala following a single episode of acute onset generalised tonic-clonic seizures. The clinical features and MRI findings of this case suggest encephalitis while swabs were found to be positive for MPXV. Next generation sequencing showed that it belonged to the A.2 lineage of clade IIb as observed in the other confirmed Monkeypox cases from India.

The patient had developed fever, headache on July 15 while in UAE, followed painful right swollen lymph nodes with pus discharge for which he had sought medical care on July 19. He was partially relieved of his symptoms and returned from UAE to Kerala, on July 21, 2022. He played football on July 23, which led to worsening of pain in the affected area. So he consulted a surgeon on July 25 in Kerala.
He continued to have fatigue and low-grade fever, which was not associated with persent headache, alteration of sensorium, loss of appetite or weight. On July 26, 2022 evening, he had a fever spike followed generalised tonic clonic seizure. Serological tests for HIV, Hepatitis B, Hepatitis C and syphilis were negative. On July 28, the patient developed features of worsening cerebral edema and was intubated and mechanically ventilated. Despite anti-cerebral edema measures, he progressed to brainstem dysfunction and succumbed on July 30, 2022. Just prior to the death of the patient, his relatives obtained a test result from the UAE, which showed that he had tested positive for MPXV in UAE on July 19, according to the study.
Researchers at ICMR NIV then confirmed the case to be infected with MPXV. In their report, they have said that this case highlights the importance of maintaining a high index of suspicion to diagnose MPXV in those presenting with atypical manifestations, exanthematous fever with epidemiological linkage from MPXV endemic or outbreak countries. The oropharyngeal/nasopharyngeal and possibly urine specimen should be considered as the critical specimens for MPXV diagnosis in cases with no active skin lesions, researchers have said.