Clinical presentation, viral kinetics, and management of human monkeypox cases from New Delhi, India 2022

We describe the clinical and demographic characteristics, virological follow‐up, and management of five confirmed monkeypox cases from New Delhi, India without any international travel history. The viral load kinetics and viral clearance were estimated in oropharyngeal swabs (OPS), nasopharyngeal swabs (NPS), EDTA blood, serum, urine, and various lesion specimens on every fourth day of follow‐up ranging from 5 to 24 post onset day (POD) of illness. All five cases presented with mild to moderate‐grade intermittent fever, myalgia, and lesions on the genitals, groins, lower limb, trunk, and upper limb. Four cases had non‐tender firm lymphadenopathy. No secondary complications or sexually transmitted infections were recorded in these cases except for the presence of viral hepatitis B infection marker hepatitis B virus surface antigen (HBsAg) in one case. All the cases were mild and had a good recovery. A higher viral load was detected in lesion fluid (POD 9), followed by lesion roof (POD 9), urine (POD 5), lesion base (POD 5), and OPS/NPS (POD 5). The monkeypox virus (MPXV) DNA was detected in clinical samples from 5th to 24th POD. These monkeypox cases without international travel history suggest the underdiagnosed monkeypox infection in the community. This emphasizes the need for active surveillance of MPXV in the high‐risk population such as men having sex with men and female sex workers.

have been linked to travel to African countries including Nigeria or associated with healthcare or household contacts as observed in the UK. 5 Since May 2022, a multicountry outbreak of monkeypox was observed across the globe affecting all six World Health Organization (WHO) regions. A total of 73 288 cases from 109 locations were found to be affected by MPXV till October 14, 2022. 6 The analysis of earlier outbreaks of MPXV (1970−2019) demonstrated a significant difference in the case fatality rate between the Central African clade (10.6%) and the West African clade (3.6%). In the 1970 outbreaks, young children were found to be affected, unlike the 2010−2019 outbreaks which affected young adults. 7 In contrast to the earlier outbreaks where both genders were almost equally affected, the current outbreak seems to have originated from the community transmission of the virus with men having sex with men (MSM) and bisexual contacts. 7,8 The clinical presentation of monkeypox disease closely resembles smallpox disease with an early occurrence of lymphadenopathy in monkeypox. In the earlier outbreaks, it was observed that classical MPXV infection starts with the maculopapular rashes, which progress to vesicles, pustules, and then scabs in a sequential manner after the completion of the prodromal febrile phase. The infection persists until the scabs fall off, which usually takes up to 4 weeks. The rashes were primarily affecting the face, arms, trunk, and lower limbs. Various other secondary complications involving encephalitis, gastrointestinal, respiratory, and corneal infections have been also observed among the patients. 9 In 2022, Bragazzi et al. 5  The WHO has recently designated the former Congo Basin (Central African) clade as Clade I and the West African clade as Clade II with two subclades IIa and IIb. 10 There are two simultaneous MPXV outbreaks currently occurring worldwide with A.2 and B.1 sublineages of clade IIb. 11 With the emergence of MPXV globally, a threat was looming over India, the second-highest populated country, connected with a huge number of daily flights across the globe. In the last two decades, importations of cases with high-risk pathogens have been seen from other countries to India that is, Ebola, Crimean−Congo hemorrhagic fever, and SARS-CoV-2 including its variants of concern that is, Alpha, Beta, and Omicron. On July 14, 2022, India reported its first human monkeypox case from Kerala. 12 Since then, 19 confirmed cases of monkeypox have been identified from Kerala (n = 6) and New Delhi (n = 13) till October 13, 2022. The cases observed in Kerala had well defined epidemiological linkage with international travel history and contact with suspected cases. 13 Unfortunately, the confirmed monkeypox cases from New Delhi have no travel history to monkeypox endemic or current outbreak areas.
Here, we describe the clinical features, viral kinetics, and management of five confirmed monkeypox cases from New Delhi, India.
The lymph nodes were non-tender and firm. Notably, cases reported

| Viral kinetics
The cases were confirmed to be positive for orthopox, monkeypox,

| Hospital management and care
All five cases were isolated in the tertiary care hospital designated for monkeypox cases for reducing secondary transmission and infection control. The patients were encouraged to wear full sleeves and fully covered clothes to prevent secondary infections in the lesions. The lesions were covered with disposal sheets to reduce exposure.
Patients were also provided with surgical masks to reduce respiratory droplets and fomites. Every 8 h, vitals were monitored including temperature, blood pressure, pulse rate, respiratory rate, and oxygen saturation. All cases were provided with symptomatic treatment that included anti-pyretic, anti-allergic, analgesics, and broad-spectrum antibiotics to prevent secondary infections. The lesions were managed with analgesic ointment, saline compress, and soft paraffin gentle massages for pustular, crusted, and dry scales, respectively.
All the common areas, isolation ward, and washrooms were disinfected with the 0.5% freshly prepared hypochlorite solution.
Healthcare workers were designated round the clock duties and used complete personal protective equipment including coveralls, N-95 masks, face shields, and double gloves for patient care activities. In our study, two cases denied in-depth details of any sexual contact which is primarily due to the stigma associated with the disease. This necessitates the counseling of monkeypox-positive cases to alleviate the fear, stigma, anxiety, stress, and depression associated with the infection.
The detection of monkeypox cases in Delhi without a travel history to endemic or affected areas suggests the undetected circulation of MPXV in the community. It has been observed and reported that transmission of MPXV through MSM was the major reason for the monkeypox outbreak in 2022. 16