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He did not remember the dose&#46; At the same time&#44; imiquimod 5&#37; cream was applied for 5 days&#44; on the suggestion of an acquaintance due to suspicion of infection by molluscum contagiosum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The examination revealed multiple umbilicated pustules with a dark center on the genitals and pubis&#44; both arms&#44; and the palms of the hands with peripustular inflammation&#46; He also presented with painful bilateral swollen inguinal lymph nodes &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Faced with suspected infection by the monkeypox virus&#44; the patient was questioned again&#46; He mentioned having been in a sauna&#44; where he maintained sexual relations with men&#44; 10 days before onset of fever and general malaise&#46; Two days later&#44; he experienced an outbreak of pustular lesions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To confirm infection with the monkeypox virus and to rule out other sexually transmitted diseases&#44; rectal exudate&#44; blood&#44; and urine samples&#44; and samples from the lesions were taken to perform the polymerase chain reaction &#40;PCR&#41; test for <span class="elsevierStyleItalic">Orthopoxvirus</span> in the National Microbiology Center in Majadahonda&#44; Madrid&#44; Spain&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient&#44; in accordance with public health recommendations&#44; self-isolated at home for approximately 10 days&#44; during which time he received oral support therapy with anti-inflammatory and antipyretic agents&#44; as well as a solution of sulfated water for the skin lesions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The PCR results were positive for the monkeypox virus and the patient progressed satisfactorily with slow resolution of the lesions&#46; Complete clearance occurred 2 weeks after the start of isolation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The case described is one of the first confirmed cases of the outbreak of monkeypox that started in Madrid during May 2022&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The monkeypox virus is transmitted to humans by contact with infected animals or humans or through material contaminated with the virus&#46; The virus penetrates the organism through solutions of continuity in the skin&#44; respiratory tract&#44; or mucus membranes&#46; The incubation period is between 6 and 16 days&#44; although it can range from 5 to 21 days&#46; There is evidence of asymptomatic monkeypox infections in individuals vaccinated against smallpox and in unvaccinated individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It is assumed that the main factor for monkeypox infection in humans is viral transmission through direct or indirect contact with living or dead animals&#46; This can occur through bites&#44; direct contact with fluids or lesions of an infected animal or contaminated material&#46; Another possible source of contagion is eating inappropriately cooked meat of an infected animal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Human&#8211;human transmission is rare&#44; but outbreaks with such transmission have been reported&#46; In addition&#44; monkeypox can be transmitted by direct contact with body fluids of an infected person or contaminated objects such as clothing and bed linen&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The capacity for detection of monkeypox virus DNA by PCR of samples from suspected skin lesions has been well established&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given that viremia is short-lasting&#44; it is preferable to obtain samples from exudate&#44; scabs&#44; or aspirate of fluid from lesions instead of blood samples&#46; Real-time PCR can discriminate not only between monkeypox virus and other <span class="elsevierStyleItalic">Orthopoxvirus</span>&#44; but also between different strains of the monkeypox virus itself&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Serology is of limited value given immunological cross-reactivity with other <span class="elsevierStyleItalic">Orthopoxvirus</span> pathogens in humans&#46; However&#44; it might be useful to rule out recent infection by <span class="elsevierStyleItalic">Orthopoxvirus</span> for contact tracing and populational serological study&#46; Immunohistochemistry may be used to identify antigens in biopsies and to rule out or identify other suspected infectious agents&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">There are no vaccines or specific treatment available for monkeypox&#46; The disease is managed by treating symptoms and providing support measures&#44; including prevention and treatment of bacterial superinfections&#46; Currently&#44; there are no specific vaccines for monkeypox&#46; First and second-generation smallpox vaccines administered during the smallpox eradication programs to all those born before March 1978 provide effective protection against the monkeypox vaccine&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Given their adverse effects&#44; these vaccines have generally not been used for control of the monkeypox virus&#46; However&#44; in the United States&#44; 30 individuals were vaccinated against smallpox in 2003 during that outbreak&#46; There is a third generation of vaccines &#40;MVA-BN&#47;Imvanex&#41; against smallpox developed for those individuals for whom the previous versions of the vaccine are contraindicated&#46; This vaccine is derived from a virus that has lost its ability to replicate in primate cells&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The vaccine has a much better safety profile than previous generations of smallpox vaccines&#46; It is approved in Europe for vaccination against smallpox in adults and was used in the United Kingdom in 2018 after cases of monkeypox were identified&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Public health measures aim to reduce human to human transmission through early recognition of cases&#44; based on clinical suspicion and laboratory tests&#44; isolation of infected patients&#44; implementation of the appropriate infection prevention and control measures in health centers &#40;standard&#44; contact&#44; aerosols&#41;&#44; and early detection of possible new cases by contact tracing and investigation of sites of outbreaks&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The smallpox vaccine can be offered to contacts&#44; including healthcare workers in contact with patients&#44; individuals exposed to the monkeypox virus at sites of outbreaks&#44; and to partners and other close contacts&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The protective effect of the human smallpox vaccine has been demonstrated in clinical trials in the 1980s&#44; with efficacy greater than 85&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41; suggests that national health authorities should offer the smallpox vaccine to those who treat patients or have been exposed to patients or samples therefrom&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">According to the Centers for Disease Control in the United States&#44; early vaccination with the smallpox vaccine&#44; that is&#44; within 14 days after exposure&#44; is an option to consider to reduce symptoms of the monkeypox virus&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Since the worldwide eradication of smallpox&#44; the vaccine for this disease is not available to the general public&#44; but several countries and the WHO maintain it in stock&#46; Smallpox vaccines manufactured with old technologies should not be administered to immunocompromised individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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Case and Research Letter
Monkeypox Virus Infection: A Case Report
Infección por virus de la viruela del mono. Caso clínico
D. Mateos Morenoa, P. Clavo Escribanob,
Autor para correspondencia
petuniaclavo@yahoo.es

Corresponding author.
a Departamento de Dermatología, Hospital Universitario de Toledo, Toledo, Spain
b Departamento de Dermatología, Centro Sanitario Sandoval, Madrid, Spain
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He did not remember the dose&#46; At the same time&#44; imiquimod 5&#37; cream was applied for 5 days&#44; on the suggestion of an acquaintance due to suspicion of infection by molluscum contagiosum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The examination revealed multiple umbilicated pustules with a dark center on the genitals and pubis&#44; both arms&#44; and the palms of the hands with peripustular inflammation&#46; He also presented with painful bilateral swollen inguinal lymph nodes &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Faced with suspected infection by the monkeypox virus&#44; the patient was questioned again&#46; He mentioned having been in a sauna&#44; where he maintained sexual relations with men&#44; 10 days before onset of fever and general malaise&#46; Two days later&#44; he experienced an outbreak of pustular lesions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To confirm infection with the monkeypox virus and to rule out other sexually transmitted diseases&#44; rectal exudate&#44; blood&#44; and urine samples&#44; and samples from the lesions were taken to perform the polymerase chain reaction &#40;PCR&#41; test for <span class="elsevierStyleItalic">Orthopoxvirus</span> in the National Microbiology Center in Majadahonda&#44; Madrid&#44; Spain&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient&#44; in accordance with public health recommendations&#44; self-isolated at home for approximately 10 days&#44; during which time he received oral support therapy with anti-inflammatory and antipyretic agents&#44; as well as a solution of sulfated water for the skin lesions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The PCR results were positive for the monkeypox virus and the patient progressed satisfactorily with slow resolution of the lesions&#46; Complete clearance occurred 2 weeks after the start of isolation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The case described is one of the first confirmed cases of the outbreak of monkeypox that started in Madrid during May 2022&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The monkeypox virus is transmitted to humans by contact with infected animals or humans or through material contaminated with the virus&#46; The virus penetrates the organism through solutions of continuity in the skin&#44; respiratory tract&#44; or mucus membranes&#46; The incubation period is between 6 and 16 days&#44; although it can range from 5 to 21 days&#46; There is evidence of asymptomatic monkeypox infections in individuals vaccinated against smallpox and in unvaccinated individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It is assumed that the main factor for monkeypox infection in humans is viral transmission through direct or indirect contact with living or dead animals&#46; This can occur through bites&#44; direct contact with fluids or lesions of an infected animal or contaminated material&#46; Another possible source of contagion is eating inappropriately cooked meat of an infected animal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Human&#8211;human transmission is rare&#44; but outbreaks with such transmission have been reported&#46; In addition&#44; monkeypox can be transmitted by direct contact with body fluids of an infected person or contaminated objects such as clothing and bed linen&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The capacity for detection of monkeypox virus DNA by PCR of samples from suspected skin lesions has been well established&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given that viremia is short-lasting&#44; it is preferable to obtain samples from exudate&#44; scabs&#44; or aspirate of fluid from lesions instead of blood samples&#46; Real-time PCR can discriminate not only between monkeypox virus and other <span class="elsevierStyleItalic">Orthopoxvirus</span>&#44; but also between different strains of the monkeypox virus itself&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Serology is of limited value given immunological cross-reactivity with other <span class="elsevierStyleItalic">Orthopoxvirus</span> pathogens in humans&#46; However&#44; it might be useful to rule out recent infection by <span class="elsevierStyleItalic">Orthopoxvirus</span> for contact tracing and populational serological study&#46; Immunohistochemistry may be used to identify antigens in biopsies and to rule out or identify other suspected infectious agents&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">There are no vaccines or specific treatment available for monkeypox&#46; The disease is managed by treating symptoms and providing support measures&#44; including prevention and treatment of bacterial superinfections&#46; Currently&#44; there are no specific vaccines for monkeypox&#46; First and second-generation smallpox vaccines administered during the smallpox eradication programs to all those born before March 1978 provide effective protection against the monkeypox vaccine&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Given their adverse effects&#44; these vaccines have generally not been used for control of the monkeypox virus&#46; However&#44; in the United States&#44; 30 individuals were vaccinated against smallpox in 2003 during that outbreak&#46; There is a third generation of vaccines &#40;MVA-BN&#47;Imvanex&#41; against smallpox developed for those individuals for whom the previous versions of the vaccine are contraindicated&#46; This vaccine is derived from a virus that has lost its ability to replicate in primate cells&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The vaccine has a much better safety profile than previous generations of smallpox vaccines&#46; It is approved in Europe for vaccination against smallpox in adults and was used in the United Kingdom in 2018 after cases of monkeypox were identified&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Public health measures aim to reduce human to human transmission through early recognition of cases&#44; based on clinical suspicion and laboratory tests&#44; isolation of infected patients&#44; implementation of the appropriate infection prevention and control measures in health centers &#40;standard&#44; contact&#44; aerosols&#41;&#44; and early detection of possible new cases by contact tracing and investigation of sites of outbreaks&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The smallpox vaccine can be offered to contacts&#44; including healthcare workers in contact with patients&#44; individuals exposed to the monkeypox virus at sites of outbreaks&#44; and to partners and other close contacts&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The protective effect of the human smallpox vaccine has been demonstrated in clinical trials in the 1980s&#44; with efficacy greater than 85&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41; suggests that national health authorities should offer the smallpox vaccine to those who treat patients or have been exposed to patients or samples therefrom&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">According to the Centers for Disease Control in the United States&#44; early vaccination with the smallpox vaccine&#44; that is&#44; within 14 days after exposure&#44; is an option to consider to reduce symptoms of the monkeypox virus&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Since the worldwide eradication of smallpox&#44; the vaccine for this disease is not available to the general public&#44; but several countries and the WHO maintain it in stock&#46; Smallpox vaccines manufactured with old technologies should not be administered to immunocompromised individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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