SciELO - Scientific Electronic Library Online
 
vol.15 número3Brote de malaria en relación con un conglomerado de casos importados en una zona fronteriza, Perú índice de autoresíndice de assuntospesquisa de artigos 		Home Pagelista alfabética de periódicos  

Serviços Personalizados

Journal

Artigo

Indicadores

  • Não possue artigos citadosCitado por SciELO

Links relacionados

  • Não possue artigos similaresSimilares em SciELO

Compartilhar

Revista del Cuerpo Médico Hospital Nacional Almanzor Aguinaga Asenjo

versão impressa ISSN 2225-5109versão On-line ISSN 2227-4731

Rev. Cuerpo Med. HNAAA vol.15 no.3 Chiclayo jul./set. 2022  Epub 30-Set-2022

http://dx.doi.org/10.35434/rcmhnaaa.2022.153.1678 

Editorial

Arboviral diseases and monkeypox An epidemiological overlapping differential diagnosis?

Arbovirosis y Viruela del Mono ¿Un diagnóstico diferencial de solapamiento epidemiológico?

Alfonso J. Rodriguez-Morales1  2  3  4  , Médico Tropicalista-Investigador Senior (MD, Tropicalist, Senior Researcher)
http://orcid.org/0000-0001-9773-2192

Darwin A. León-Figueroa5  6  , Estudiante de Medicina (Medical Student)
http://orcid.org/0000-0001-7267-0204

Ranjit Sah7  8  , Médico Infectólogo (Infectious Diseases Physician)
http://orcid.org/0000-0002-5158-5550

Wilmer E. Villamil-Gomez8  9  , Médico Epidemiólogo (MD, Epidemiologist)
http://orcid.org/0000-0002-5492-3455

1 Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia. alfonso.rodriguez@uam.edu.co

2 Institución Universitaria Visión de las Américas, Pereira, Risaralda, Colombia.

3 Master of Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Perú.

4 School of Medicine, Universidad Privada Franz Tamayo (UNIFRANZ), Cochabamba, Bolivia.

5 Universidad de San Martín de Porres, Facultad de Medicina Humana, Chiclayo, Perú.

6 Emerge, Unidad de Investigación en Enfermedades Emergentes y Cambio Climático, Facultad de Salud Pública y Administración, Universidad Peruana Cayetano Heredia. Lima, Perú.

7 Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal.

8 Harvard University, Medical School, Boston, USA.

9 Infectious Diseases and Infection Control Research Group, Hospital Universitario de Sincelejo, Sincelejo, Sucre, Colombia.

Over the last decades, the epidemiological importance of different arboviral diseases in the world has been significant, especially in Latin America and South-East Asia &left;1&right;. Dengue, chikungunya, Zika, yellow fever, but also Venezuelan Equine Encephalitis, Mayaro, and Oropouche, among others, have been significantly important in the case of Latin America &left;2,3&right;. Multiple dengue epidemics and the recent 2014-2015 epidemics of chikungunya &left;4,5&right; or 2015-2016 of Zika &left;2,4,6,7&right; have been a matter of concern. Furthermore, during the COVID-19 pandemic, coinfections with arboviruses and other tropical pathogens have also been relevant &left;4-6&right;. That is important to consider as a differential diagnosis and the possibility of coinfections.

Now, another reemerging viral zoonotic disease is a cause of concern and declared on July 23, 2022, a Public Health Emergency of International Concern, monkeypox &left;7,8&right;. By August 5, 2022, monkeypox spread to 93 countries that have not historically reported the disease, for a total of more than 52,000 cases, affecting multiple continents, including Latin America &left;9&right;. Moreover, monkeypox is creating numerous preoccupations regarding the ways of transmission (e.g. sexually possible) &left;10&right;, populations affected (e.g. HIV people) &left;11,12&right;, and especially the shift in the clinical presentation &left;13-15&right;.

Monkeypox in 2022 is no longer presenting predominantly as a clinical course of fever, chills, and lymphadenopathy with a subsequent rash after 3-5 days of prodrome. Instead, it presents predominantly as a genital rash or ulcers syndrome, similar to other sexually transmitted infections. Nevertheless, the rash may occur with high variation in presentation, from single to multiple lesions, in multiple body areas &left;10,13-17&right;. Given this situation, it is essential to consider differential diagnoses of exanthematic or eruptive type that explain the clinical presentation and correspond to the local epidemiological situation, including chickenpox, herpes zoster, measles, hands, feet, and mouth (coxsackie virus), herpes simplex, genital herpes, bacterial infections of the skin (impetigo), disseminated gonococcal infection, primary or secondary syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, molluscum contagiosum, allergic reaction (even including Steven-Johnson syndrome), but also arboviruses, especially Zika, dengue, and chikungunya (Table 1).

Well-known arboviral diseases such as dengue, Zika and chikungunya may develop rash &left;2&right;, monkeypox, yellow fever and Mayaro. Yellow fever has been reemerging recently, causing cases and outbreaks in Brazil, Peru, and Venezuela &left;18&right;. Then, in Latin America, especially in Brazil, Colombia, Peru, Venezuela, and Panama, among others, such differential diagnosis should carefully assess the possible identification of arboviruses as the cause of the rash, considering monkeypox, but also the possibility of coinfections (Table 1). So far, no cases of coinfections between monkeypox and arboviral diseases have been reported. But monkeypox coinfections with HIV, other sexually transmitted infections, especially syphilis, and even SARS-CoV-2/COVID-19 &left;19&right;, have already been registered &left;10,12&right;.

Given the current reemergence of dengue in some countries of Latin America (e.g. Colombia with 43,123 cases up to August 27, 2022), the ongoing outbreak of monkeypox may yield especially the concern of overlapping and epidemiological interaction between these two conditions. Therefore, physicians in primary care should have a high level of suspicion for both needs, especially for dengue, which may evolve more into a severe disease and fatal outcomes. In the case of monkeypox, such concern is significant among immunosuppressed patients or those with comorbidities. So far, the case fatality rate in 2022 has been estimated at 0.01% &left;19&right;.

Finally, multiple lessons from the recent past, multiple epidemics of arboviral diseases, and the current COVID-19 pandemic are essential to understanding the epidemiological trend, strategies and containment &left;20&right;, but also to provide logical clinical reasoning when considering differential diagnoses and even possibilities of coinfection, in this case, between monkeypox and arboviral diseases.

Table 1 Clinical comparison between arboviral diseases and monkeypox. 

  CHIK DEN MA ZIKA YELLOW MONKEY
Fever +++ ++++ ++++ ++/0a +++ ++++/0d
Myalgia/arthralgia ++++ +++ +++ ++ + ++/0d
Edema in limbs 0 0 0 ++ 0 0
Maculopapular rash ++ ++ ++ +++ b 0 +++e
Vesiculopapular rash 0 0 0 0 0 ++++e
Retro-ocular pain + +++ ++ ++ 0 0
Conjunctivitis, non-purulent + 0 0 +++ 0 +/0d
Lymphadenopathies ++ ++ + + 0/+ ++++/0d
Hepatomegaly ++ 0 + 0 +++ 0
Leukopenia/ thrombocytopenia ++ ++++ ++ 0/+c +++ Leukocytosis/ Thrombocytopenia++
Haemorrhages + +++ 0 0/+c ++++ +/0d
Headache + +++ + + +++ ++/0d
Lumbago ++ + + 0 +++ 0
Asthenia + ++ + 0 ++ +++/0d

CHIK, chikungunya; DEN, dengue; MA, mayaro; ZIKA, Zika; YELLOW, yellow fever; MONKEY, Monkeypox.

Bold indicates which of the arboviruses is the highest frequency of the clinical finding.

aDepends on the geography and phylogeny of the virus, in some areas, patients do not present fever.

bPruriginous (mild to severe).

cIn some cases, these findings have been reported.

dIn the 2022 clinical phenotype, such a finding may not be present.

eIn these cases, with intense pruritus and pain.

References

1. Musso D, Rodriguez-Morales AJ, Levi JE, Cao-Lormeau VM, Gubler DJ. Unexpected outbreaks of arbovirus infections: lessons learned from the Pacific and tropical America. Lancet Infect Dis. 2018;18:e355-e61. [ Links ]

2. Paniz-Mondolfi AE, Rodriguez-Morales AJ, Blohm G, Marquez M, Villamil-Gomez WE. ChikDenMaZika Syndrome: the challenge of diagnosing arboviral infections in the midst of concurrent epidemics. Ann Clin Microbiol Antimicrob. 2016;15:42. [ Links ]

3. Villamil-Gomez W, Merlano JR, Bonilla-Aldana K, Salas-Matta LA, Rodriguez-Morales AJ. Arbovirosis endemoepidemicas. Medicine - Programa de Formacion Medica Continuada Acreditado. 2022;13:3398-414. [ Links ]

4. Ortiz-Martinez Y, Mogollon-Vargas JM, Lopez-Rodriguez M, Rodriguez-Morales AJ. A fatal case of triple coinfection: COVID-19, HIV and Tuberculosis. Travel medicine and infectious disease. 2021;43:102129. [ Links ]

5. Mejia-Parra JL, Aguilar-Martinez S, Fernandez-Mogollon JL, Luna C, Bonilla-Aldana DK, Rodriguez-Morales AJ, et al. Characteristics of patients coinfected with Severe Acute Respiratory Syndrome Coronavirus 2 and dengue virus, Lambayeque, Peru, May-August 2020: A retrospective analysis. Travel medicine and infectious disease. 2021;43:102132. [ Links ]

6. Villamil-Gomez WE, Rojas-Torres I, Perea-Vasquez LE, Collazos-Torres LA, Murillo-Moreno MA, Morales-Rudas JD, et al. SARS-CoV-2 and Dengue virus co-infection: A case from North Caribbean Colombia. Travel medicine and infectious disease. 2021;43:102096. [ Links ]

7. Leon-Figueroa DA, Bonilla-Aldana DK, Pachar M, Romani L, Saldana-Cumpa HM, Anchay-Zuloeta C, et al. The never ending global emergence of viral zoonoses after COVID-19? The rising concern of monkeypox in Europe, North America and beyond. Travel medicine and infectious disease. 2022;49:102362. [ Links ]

8. Sah R, Reda A, Lashin BI, Mohanty A, Abdelaal A, Rodriguez-Morales AJ. Public health emergencies of international concernin the 21st century. Annals of medicine and surgery (2012). 2022;81:104417. [ Links ]

9. Rodriguez-Morales AJ, Lopardo G, Verbanaz S, Orduna T, Lloveras S, Azenas-Burgoa JM, et al. Latin America: Situation and preparedness facing the multi-country human monkeypox outbreak. Lancet Regional Health Americas. 2022;13:100318. [ Links ]

10. Rodriguez-Morales AJ, Lopardo G. Monkeypox: Another Sexually Transmitted Infection? Pathogens. 2022;11:713. [ Links ]

11. Farahat RA, Abdelaal A, Shah J, Ghozy S, Sah R, Bonilla-Aldana DK, et al. Monkeypox outbreaks during COVID-19 pandemic: are we looking at an independent phenomenon or an overlapping pandemic? Ann Clin Microbiol Antimicrob. 2022;21:26. [ Links ]

12. Ortiz-Martinez Y, Zambrano-Sanchez G, Rodriguez-Morales AJ. Monkeypox and HIV/AIDS: When the outbreak faces the epidemic. International journal of STD & AIDS. 2022:9564624221114191. [ Links ]

13. Benites-Zapata VA, Ulloque-Badaracco JR, Alarcon-Braga EA, Hernandez-Bustamante EA, Mosquera-Rojas MD, Bonilla-Aldana DK, et al. Clinical features, hospitalisation and deaths associated with monkeypox: a systematic review and meta-analysis. Ann Clin Microbiol Antimicrob. 2022;21:36. [ Links ]

14. Rodriguez-Morales AJ. Monkeypox and the importance of cutaneous manifestations for disease suspicion. Microbes, Infection and Chemotherapy. 2022;2:e1450. [ Links ]

15. Ortiz-Martinez Y, Rodriguez-Morales AJ, Franco-Paredes C, Chastain DB, Gharamti AA, Vargas Barahona L, et al. Monkeypox ï¿1/2 a description of the clinical progression of skin lesions: a case report from Colorado, USA. Therapeutic Advances in Infectious Disease. 2022;9:20499361221117726. [ Links ]

16. Cimerman S, Chebabo A, Cunha CAD, Barbosa AN, Rodriguez-Morales AJ. Human monkeypox preparedness in Latin America - Are we ready for the next viral zoonotic disease outbreak after COVID-19? The Brazilian journal of infectious diseases : an official publication of the Brazilian Society of Infectious Diseases. 2022;26:102372. [ Links ]

17. Sah R, Abdelaal A, Asija A, Basnyat S, Sedhai YR, Ghimire S, et al. Monkeypox Virus Containment: The Application of Ring Vaccination and Possible Challenges. J Travel Med. 2022. [ Links ]

18. Rodriguez-Morales AJ, Bonilla-Aldana DK, Suarez JA, Franco-Paredes C, Forero-Pena DA, Mattar S, et al. Yellow fever reemergence in Venezuela - Implications for international travelers and Latin American countries during the COVID-19 pandemic. Travel medicine and infectious disease. 2021;44:102192. [ Links ]

19. Sah R, Mohanty A, Abdelaal A, Reda A, Rodriguez-Morales AJ, Henao-Martinez AF. First Monkeypox deaths outside Africa: no room for complacency. Ther Adv Infect Dis. 2022;9:20499361221124027. [ Links ]

20. Rodriguez-Morales AJ, Paniz-Mondolfi AE, Faccini-Martinez A A, Henao-Martinez AF, Ruiz-Saenz J, Martinez-Gutierrez M, et al. The Constant Threat of Zoonotic and Vector-Borne Emerging Tropical Diseases: Living on the Edge. Frontiers in tropical diseases. 2021;2:676905. [ Links ]

CORRESPONDENCE Alfonso J. Rodriguez-Morales EMAIL: ajrodriguezmmd@gmail.com

authors declared no conflict of interest.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License

 
Plaza de la Seguridad Social s/n. Chiclayo, Perú.