Conjunctivitis in patient with monkeypox: Possible mode of disease transmission

Spanish investigators from the Ophthalmology Service, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, led by first author Fernando Ly-Yang, MD, reported the case of a 42-year-old man with monkeypox. The patient had HIV and presented with conjunctivitis.¹ 

The patient’s symptoms included lacrimation, pain, and photophobia of the left eye for 6 days. Facial maculopapular lesions developed on his face and foot on the 5th day after symptom onset. The patient had a fever and painful cervical adenopathy and was HIV positive.

The patient had not traveled recently or had contact with monkeypox cases. However, his boyfriend worked in a sex club and had a fever.

Slit-lamp examination of the affected eye showed ulcerations on the eyelid margin, mucoid discharge, and conjunctival whitish, serpinginous, infiltrative lesions with conjunctival thickening. The cornea was unaffected.

Dermatologic evaluation of the skin resulted in a clinical diagnosis with high suspicion for monkeypox.

Polymerase chain reaction testing of the conjunctiva and skin was positive for monkeypox and negative for herpes viruses.

The authors reported that the patient received systemic treatment with 600 mg tecovirimat every 12 hours and intravenous acyclovir 1 gram every 8 hours, and topical zinc sulfate every 8 hours on the skin lesions. Ocular topical treatment included the following drops administered 5 times daily: chlorhexidine 0.2%, ganciclovir 0.15%, moxifloxacin, and povidone iodine 1%.

During the second week of treatment, conjunctival pseudomembranes developed during the second week of treatment. The pseudomembranes were removed and and topical fluorometholone 4 times daily was started.

The skin lesions resolved first and the conjunctival lesions resolved after 4 weeks of treatment.

The authors pointed out that conjunctivitis has been reported in 23% of monkeypox cases, but generally the male patients are younger than 10 years and have other symptoms in contrast to the current patient who was 42 years and did not have systemic signs or symptoms.

“The presence of conjunctival inflammation could occur more often in immunocompromised individuals given that the patient was HIV positive or it could be due to the contiguous spread of the periocular skin lesions,” the investigators wrote.

The investigators also noted that it is unknown if monkeypox is secreted in tears during conjunctivitis. However, the smallpox virus is secreted in tears, and monkeypox is a similar virus. Therefore, conjunctivitis may transmit the disease.

“A case of monkeypox in a patient with HIV with conjunctivitis is documented,” investigators concluded. “Conjunctivitis associated with monkeypox might present before skin lesions and may be a way of transmitting the disease.”

Reference

Ly-Yang F, Miranda-Sánchez A, Burgos-Blasco B, et al. Conjunctivitis in an individual with monkeypox. JAMA Ophthalmol. Published Online September 7, 2022. doi:10.1001/jamaophthalmol.2022.3743