Response to ‘Clinical spectrum of human monkeypox: An Italian single‐centre case series’. The experience of an STD Centre in Florence

Dear Editor, We have read with great interest the paper by Aromolo et al.1 entitled ‘Clinical spectrum of human monkeypox: An Italian single-centre case series’. We also observed six cases of confirmed human monkeypox virus (MPXV) infection in the period between June and September 2022 at the sexually transmitted diseases (STD) centre of the dermatology unit of Florence (Table 1). Polymerase chain reaction assays of swabs obtained from the oropharynx and mucocutaneous lesions were all positive for MPXV DNA. All six patients identified themselves as men who have sex with men (MSM); five of them were Italian and one was Norwegian. Each of them reported condomless sexual intercourse with different casual partners, Italians and foreigners, in the last month. All denied any recent travel in a specific endemic country. Four had at least a previous STD and three were living with the human immunodeficiency virus (HIV), under highly active antiretroviral therapy (HAART) with a good viro-immunological response. Two of them, the older ones, had been vaccinated against smallpox. The genital area was the most commonly affected body site (4/6 patients) at the onset of the disease also in our case series2 (Figure 1a). Instead, two patients started with oral involvement.3 Only one patient showed the classic centrifugal progression of the mucocutaneous rash, with the development of a large number of lesions and involvement of trunk, limbs, hands, feet and perianal region (Figure 1b,c). In this case, cutaneous manifestations consisted of vesiculo-pustular, umbilicated, lesions with peripheral erythematous halo, not all in the same stage of development and evolved asynchronously in crusts with desquamative collarette. Dermoscopy showed whitish structureless areas with a brownish central depression and peripheral erythema (Figure 1d). Two patients with lesions that started on the penis and scrotum did not report the development of any other lesions during home isolation. In three patients in whom the initial lesion developed on the foreskin of the penis, tongue and floor of the mouth, respectively, an atypical dissemination of the rash appeared with development of only one to three single vesiculo-pustular lesions in other anatomical sites (nipple, hand, nose, penis shaft, wrist). However, one of these three patients additionally developed a non-pruriginous papular rash on his trunk that did not evolve in a pustular or ulcerated one. This finding represents an additional change in the clinical presentation of this multifaceted disease. Although the numbers are too small to draw conclusions, we can say that in our limited case series HIV-positive patients developed more severe clinical manifestations with persistent fever for several days and other systemic symptoms such as malaise, sore throat and lymphadenopathy. Considering the three HIV-negative patients, two developed only a few mucocutaneous lesions without systemic involvement, one reported low-grade fever for 2 days followed by the appearance of two isolated genital pustules. Even if HIV-positive patients of our series were all on HAART with undetectable viral load and good CD4+ count, it is possible that the concomitant MPXV infection has led to a transient weakening of the immune system with consequent more severe clinical manifestations. In all our cases, it seems possible to trace a correlation between the type of sexual intercourse and the anatomical site of the onset of mucocutaneous lesions. We also did not observe a correlation between infection and travel abroad, as to suggest the presence of a locoregional small cluster. The clinical evolution is extremely variable and unpredictable from individual to individual, probably it is linked to a whole series of virological and immune factors as yet not well identified. Our data highlight the need of collecting and comparing more case series of confirmed MPXV from other centres to understand the possibility of a correlation between the severity of clinical manifestations and HIV seropositivity. None. None. The patients in this manuscript have given written informed consent to the publication of their case details.