Oral, Nasal, Urine Samples Critical Specimens For Monkeypox Diagnosis: ICMR Study On India's First Fatal Case

The study reports that in cases with no active skin lesions, oropharyngeal swabs (OPS), nasopharyngeal swabs (NPS) and urine samples should be considered as critical specimens for monkeypox diagnosis.

After India recorded its first fatal case of monkeypox in July, the Indian Council of Medical Research (ICMR) conducted a study to obtain key insights into monkeypox infection. The study reports that in cases with no active skin lesions, oropharyngeal swabs (OPS), nasopharyngeal swabs (NPS) and urine samples should be considered as critical specimens for monkeypox diagnosis. The first fatal case of monkeypox in India from Kerala highlights the importance of maintaining a high index of suspicion to diagnose the viral disease in the people exhibiting atypical manifestations and exanthematous fever (illness that produces skin infection), the study states, news agency PTI reports. The study describing the findings was published as a pre-print on September 14.

As many as 11 cases of monkeypox have been reported in India so far. Of these, five are from Kerala and six are from Delhi.

India's First Fatal Case: Timeline Of Events From Monkeypox Infection To Death

The Indian patient who died due to monkeypox was a 22-year-old male with no significant past medical history, the report says. Following a single episode of acute onset generalised tonic-clonic seizures, he was admitted in an unconscious state to a private hospital in Kerala. Tonic-clonic seizures involve stiffening and twitching of a person’s muscles, according to Johns Hopkins Medicine.

On July 15, the patient developed a fever and headache. At that time, he was in the UAE. The fever and headache were followed by the development of painful right inguinal lymphadenopathy with pus discharge. Inguinal lymphadenopathy often accompanies groin infection and is characteristic of inflammatory pathology almost anywhere in the groin. Following this, the person sought medical care on July 19. 

On July 21, he returned from the UAE to Kerala after he was partially relieved of his symptoms. On July 23, he played football. This worsened the pain in his right inguinal area. For this, he consulted a surgeon on July 25 in Kerala. There, he was diagnosed with hidradenitis suppurativa. This is a painful, long-term skin condition that causes abscesses and scarring on the skin.

According to the PTI report, the person continued to experience fatigue and low-grade fever. The fever was not associated with persistent headache, alteration of sensorium, loss of appetite or weight. On July 26, the person had a fever spike. This was followed by generalised tonic-clonic seizure. He underwent serological tests for HIV, Hepatitis B, Hepatitis C, and syphilis. 

The person tested negative for all these diseases, the report says. Initially, the man had neutrophilic leukocytosis with normal hepatic and renal function. This is a condition in which the body produces an abnormally high number of neutrophils, a type of white blood cells. He subsequently developed coagulopathy and acute kidney injury, the study states. Coagulopathy is a bleeding disorder in which the blood’s ability to coagulate is impaired.

On July 28, the person developed features of worsening cerebral edema, a term used to describe swelling of the brain. After this, he was mechanically ventilated.

Anti-cerebral edema measures were taken. Despite this, he progressed to brainstem dysfunction. On July 30, he succumbed to his illness. 

The patient’s relatives obtained a test result from the UAE, just before his test. The tests showed that the person had tested positive for monkeypox virus in the UAE on July 19, the report says.

The study states that the oropharyngeal and nasopharyngeal samples, and urine samples, should be considered as critical specimens for monkeypox virus diagnosis in cases with no active skin lesions. The study concludes that the overall findings of the case and the history confirm the case to be monkeypox.

The PTI report says that in 2022, a total of 15 fatalities have been reported globally from endemic and non-endemic countries.

Current Monkeypox Outbreak Largely Limited To Men Who Have Sex With Men

The current monkeypox outbreak has largely been limited to the community of men who have sex with men, especially those with multiple bisexual or homosexual partners. 

Scientists have detected the monkeypox virus in anal samples taken from asymptomatic men who have sex with men. This means that asymptomatic infection may be a cause for concern in the monkeypox outbreak, according to a new study. 

Vaccination limited to the persons with known exposure to the monkeypox virus may not be an effective strategy for preventing infection, the findings suggest. The study describing the results was recently published in the journal Annals of Internal Medicine. 

Most of the persons infected with monkeypox have recovered. Immunocompromised individuals have experienced complications such as sepsis (potentially life-threatening condition that occurs when the body’s response to an infection damages its own tissues) and encephalitis (inflammation of the brain).

Fatal cases of monkeypox infection in Brazil and Mexico were primarily reported in immunocompromised individuals. Meanwhile, in Spain, the fatal cases were immunocompetent, and had no underlying conditions.

Scientists do not know yet whether or not asymptomatic infection will play a role in the transmission of monkeypox virus. However, the current worldwide monkeypox epidemic and the mode of human-to-human transmission may suggest that asymptomatic or preclinical spread can occur.