Neonatal Monkeypox Virus Infection | NEJM

For the editor:

The ongoing monkeypox outbreak was recently declared a public health emergency of international concern by the World Health Organization.1 Young children are at risk for serious illness; therefore, early detection and prompt treatment are important.2

Monkeypox skin lesions in a newborn.

Monkeypox skin lesions on the hands and feet of a newborn baby are shown. Visible lesions range from vesicles to pustules, and lesions that were beginning to crust are also shown. Photographs were obtained on day 5 after rash onset.

We report a case of perinatal infection with monkeypox virus and co-infection with adenovirus in a 10-day-old infant. Following the infant’s uneventful birth in late April 2022, a rash developed on day 9 of life. The rash was initially blistering, beginning on the palms and soles of the feet and then spreading to the face and trunk, and gradually became pustular (Figure 1). Nine days before the birth, the child’s father had had a feverish illness, followed by a generalized rash; the rash resolved before the infant was born. Four days after the infant was delivered, a similar rash developed in the mother. The family lived in the UK and there was no history of travel to Africa or contact with travellers.

The infant was transferred to the regional pediatric intensive care unit on day 15 of life with progressive hypoxemic respiratory failure (Fig. S1 in the Supplementary Appendix, available with the full text of this letter on NEJM. org). A number of diagnoses (neonatal varicella, herpes simplex virus infection, coxsackievirus or enterovirus infection, staphylococcal skin infection, scabies, syphilis, and gonorrhea) were considered. The presence of axillary lymphadenopathy, the nature of the skin lesions, and the atypical timing of intrafamilial infection have raised concerns about human monkeypox. Polymerase chain reaction tests on blood, urine, vesicular fluid, and throat swab samples taken from the infant and mother led to a diagnosis of monkeypox virus (clade IIb) infection. Adenovirus has also been identified in respiratory secretions and infant blood. The infant’s condition worsened and invasive ventilation was initiated. A 2-week course of enteric tecovirimat (at a dose of 50 mg twice daily) was started in combination with intravenous cidofovir. After 4 weeks in intensive care, including 14 days of invasive ventilation, the infant recovered and was discharged home. The intrafamilial infection timeline and test results are shown in Figure S2.

Cases of neonatal monkeypox virus infection are rare.3 This was a case of neonatal infection with the monkeypox virus after peripartum transmission within a family cluster; transplacental transmission cannot be excluded.4 As this was a single case, it is not possible to directly attribute the clinical illness to either pathogen (monkeypox virus or adenovirus), nor to attribute the improvement from the clinical status of the infant to the use of tecovirimat or cidofovir.5 Monkeypox virus infection should be considered in the differential diagnosis of neonatal blistering rash.

Padmanabhan Ramnarayan, MD
Imperial College London, London, United Kingdom
[email protected]

Rebecca Mitting, MB, BS
Imperial College Healthcare NHS Trust, London, UK

Elizabeth Whittaker, Ph.D.
Imperial College London, London, United Kingdom

Maria Marcolin, MRCPCH
Ciara O’Regan, MRCPCH
Ruchi Sinha, MRCPCH
Aisleen Bennett, Ph.D.
Moustafa Moustafa, MRCPCH
Neil Tickner, M.Pharm.
Mark Gilchrist, M.Sc.
Imperial College Healthcare NHS Trust, London, UK

Anthony Kershaw, MRCPCH
London Northwest University Healthcare NHS Trust, London, UK

Tommy Rampling, D. Phil.
UK Health Security Agency, London, UK

The disclosure forms provided by the authors are available with the full text of this letter on NEJM.org.

This letter was published on October 12, 2022 on NEJM.org.

A list of NHS England High Consequence Infectious Diseases (Airborne) network members is provided in the Supplementary Appendix, available at NEJM.org.

  1. 1. World Health Organization. Multi-Country Monkeypox Outbreak, External Situation Report No. 3 — August 10, 2022 (https://www.who.int/publications/m/item/multi-country-outbreak-of-monkeypox–external-situation- report- -3—10-August-2022).

  2. 2. Meyer H, Perrichot M, Stemmler M, et al. Disease outbreaks suspected to be due to human monkeypox virus infection in the Democratic Republic of the Congo in 2001. J Clin Microbiol 2002;40:29192921.

  3. 3. Yinka-Ogunleye A, Aruna O, Dalhat M, et al. Human monkeypox epidemic in Nigeria in 2017-2018: a clinical and epidemiological report. Lancet Infect Dis 2019;19:872879.

  4. 4. Mbala PK, HugginsJW, Riu Rovira T, et al. Maternal and fetal outcomes in pregnant women infected with human monkeypox in the Democratic Republic of the Congo. J Infect Dis 2017;216:824828.

  5. 5. Sherwat A, Brooks J.T., Birkrant D, Kim P.. Tecovirimat and the treatment of monkeypox – past, present and future considerations. N English J med 2022;387:579581.

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