Emerging Infections

Non–Lyme disease, tick-borne illnesses — such as spotted fever group rickettsiosis (SFGR), ehrlichiosis, and alpha-gal syndrome (AGS) — are emerging public health threats, but whether prior tick exposures are responsible for long-term complications, such as musculoskeletal symptoms or osteoarthritis, has been unclear.

Many patients attribute their nonspecific long-term symptoms, such as musculoskeletal pain, to previous illnesses from tick bites, note authors of a study published in JAMA Network Open. But the researchers, led by Diana L. Zychowski, MD, MPH, with the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, found that Ehrlichia or Rickettsia seropositivity was not associated with chronic musculoskeletal symptoms, though they write that “further investigation into the pathogenesis of [alpha-gal] syndrome is needed.”
 

Tick-Borne Illness Cases Multiplying

Cases of tick-borne illness (TBD) in the United States have multiplied in recent years. More than 50,000 cases of TBD in the United States were reported in 2019, which doubled the number of cases over the previous 2 decades, the authors note.

Most of the cases are Lyme disease, but others — including SFGR and ehrlichiosis — represent an important public health threat, especially in southeastern states, the authors write. Cases of ehrlichiosis, for example, transmitted by the lone star tick, soared more than 10-fold since 2000.

The goal of this study was to evaluate whether there was an association between prior exposure to TBDs endemic to the southeastern United States and chronic musculoskeletal symptoms and radiographic measures of osteoarthritis.

Researchers analyzed 488 blood samples from the fourth visit (2017-2018) of the Johnston County Osteoarthritis (JoCo OA) project, an ongoing population-based study in Johnston County, North Carolina. JoCo OA participants include noninstitutionalized White and Black Johnston County residents 45 years old or older with osteoarthritis.

They measured seroprevalence of Rickettsia- and Ehrlichia-specific immunoglobulin G (IgG) as well as alpha-gal immunoglobulin E (IgE) in patient samples. Only alpha-gal IgE was linked in the study with knee pain, aching, or stiffness. Antibodies to Rickettsia, Ehrlichia, and alpha-gal were not associated with radiographic, symptomatic knee osteoarthritis.

“To our knowledge,” the authors write, “this study was the first population-based seroprevalence study of SFGR, Ehrlichia, and [alpha]-gal.”

The study also found a high prevalence of TBD exposure in the cohort. More than a third (36.5%) had either an alpha-gal IgE level greater than 0.1 IU/mL, a positive test for SFGR IgG antibodies, or a positive test for Ehrlichia IgG antibodies.

Given that not every tick carries an infectious pathogen, the findings show human-tick interactions are common, they write.

“These findings suggest that substantial investment is required to examine the pathogenesis of these TBDs and interventions to reduce human-tick interactions,” the authors conclude.

This study was funded by a Creativity Hub Award from the University of North Carolina Office of the Vice Chancellor for Research. The JoCo OA project is supported in part by grants from the Association of Schools of Public Health/Centers for Disease Control and Prevention (CDC); and grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Authors reported grants from the National Institutes of Health, the CDC, and several pharmaceutical companies.

Non–Lyme disease, tick-borne illnesses — such as spotted fever group rickettsiosis (SFGR), ehrlichiosis, and alpha-gal syndrome (AGS) — are emerging public health threats, but whether prior tick exposures are responsible for long-term complications, such as musculoskeletal symptoms or osteoarthritis, has been unclear.

Many patients attribute their nonspecific long-term symptoms, such as musculoskeletal pain, to previous illnesses from tick bites, note authors of a study published in JAMA Network Open. But the researchers, led by Diana L. Zychowski, MD, MPH, with the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, found that Ehrlichia or Rickettsia seropositivity was not associated with chronic musculoskeletal symptoms, though they write that “further investigation into the pathogenesis of [alpha-gal] syndrome is needed.”
 

Tick-Borne Illness Cases Multiplying

Cases of tick-borne illness (TBD) in the United States have multiplied in recent years. More than 50,000 cases of TBD in the United States were reported in 2019, which doubled the number of cases over the previous 2 decades, the authors note.

Most of the cases are Lyme disease, but others — including SFGR and ehrlichiosis — represent an important public health threat, especially in southeastern states, the authors write. Cases of ehrlichiosis, for example, transmitted by the lone star tick, soared more than 10-fold since 2000.

The goal of this study was to evaluate whether there was an association between prior exposure to TBDs endemic to the southeastern United States and chronic musculoskeletal symptoms and radiographic measures of osteoarthritis.

Researchers analyzed 488 blood samples from the fourth visit (2017-2018) of the Johnston County Osteoarthritis (JoCo OA) project, an ongoing population-based study in Johnston County, North Carolina. JoCo OA participants include noninstitutionalized White and Black Johnston County residents 45 years old or older with osteoarthritis.

They measured seroprevalence of Rickettsia- and Ehrlichia-specific immunoglobulin G (IgG) as well as alpha-gal immunoglobulin E (IgE) in patient samples. Only alpha-gal IgE was linked in the study with knee pain, aching, or stiffness. Antibodies to Rickettsia, Ehrlichia, and alpha-gal were not associated with radiographic, symptomatic knee osteoarthritis.

“To our knowledge,” the authors write, “this study was the first population-based seroprevalence study of SFGR, Ehrlichia, and [alpha]-gal.”

The study also found a high prevalence of TBD exposure in the cohort. More than a third (36.5%) had either an alpha-gal IgE level greater than 0.1 IU/mL, a positive test for SFGR IgG antibodies, or a positive test for Ehrlichia IgG antibodies.

Given that not every tick carries an infectious pathogen, the findings show human-tick interactions are common, they write.

“These findings suggest that substantial investment is required to examine the pathogenesis of these TBDs and interventions to reduce human-tick interactions,” the authors conclude.

This study was funded by a Creativity Hub Award from the University of North Carolina Office of the Vice Chancellor for Research. The JoCo OA project is supported in part by grants from the Association of Schools of Public Health/Centers for Disease Control and Prevention (CDC); and grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Authors reported grants from the National Institutes of Health, the CDC, and several pharmaceutical companies.

Non–Lyme disease, tick-borne illnesses — such as spotted fever group rickettsiosis (SFGR), ehrlichiosis, and alpha-gal syndrome (AGS) — are emerging public health threats, but whether prior tick exposures are responsible for long-term complications, such as musculoskeletal symptoms or osteoarthritis, has been unclear.

Many patients attribute their nonspecific long-term symptoms, such as musculoskeletal pain, to previous illnesses from tick bites, note authors of a study published in JAMA Network Open. But the researchers, led by Diana L. Zychowski, MD, MPH, with the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, found that Ehrlichia or Rickettsia seropositivity was not associated with chronic musculoskeletal symptoms, though they write that “further investigation into the pathogenesis of [alpha-gal] syndrome is needed.”
 

Tick-Borne Illness Cases Multiplying

Cases of tick-borne illness (TBD) in the United States have multiplied in recent years. More than 50,000 cases of TBD in the United States were reported in 2019, which doubled the number of cases over the previous 2 decades, the authors note.

Most of the cases are Lyme disease, but others — including SFGR and ehrlichiosis — represent an important public health threat, especially in southeastern states, the authors write. Cases of ehrlichiosis, for example, transmitted by the lone star tick, soared more than 10-fold since 2000.

The goal of this study was to evaluate whether there was an association between prior exposure to TBDs endemic to the southeastern United States and chronic musculoskeletal symptoms and radiographic measures of osteoarthritis.

Researchers analyzed 488 blood samples from the fourth visit (2017-2018) of the Johnston County Osteoarthritis (JoCo OA) project, an ongoing population-based study in Johnston County, North Carolina. JoCo OA participants include noninstitutionalized White and Black Johnston County residents 45 years old or older with osteoarthritis.

They measured seroprevalence of Rickettsia- and Ehrlichia-specific immunoglobulin G (IgG) as well as alpha-gal immunoglobulin E (IgE) in patient samples. Only alpha-gal IgE was linked in the study with knee pain, aching, or stiffness. Antibodies to Rickettsia, Ehrlichia, and alpha-gal were not associated with radiographic, symptomatic knee osteoarthritis.

“To our knowledge,” the authors write, “this study was the first population-based seroprevalence study of SFGR, Ehrlichia, and [alpha]-gal.”

The study also found a high prevalence of TBD exposure in the cohort. More than a third (36.5%) had either an alpha-gal IgE level greater than 0.1 IU/mL, a positive test for SFGR IgG antibodies, or a positive test for Ehrlichia IgG antibodies.

Given that not every tick carries an infectious pathogen, the findings show human-tick interactions are common, they write.

“These findings suggest that substantial investment is required to examine the pathogenesis of these TBDs and interventions to reduce human-tick interactions,” the authors conclude.

This study was funded by a Creativity Hub Award from the University of North Carolina Office of the Vice Chancellor for Research. The JoCo OA project is supported in part by grants from the Association of Schools of Public Health/Centers for Disease Control and Prevention (CDC); and grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Authors reported grants from the National Institutes of Health, the CDC, and several pharmaceutical companies.

A new analysis supports using the smallpox antiviral tecovirimat (TPOXX/ST-246) in HIV patients showing the first symptoms of the human smallpox disease mpox (monkeypox), caused by the variola virus.

In a small prospective matched cohort analysis, people with HIV (PWH) and mpox disease who received tecovirimat within 7 days of symptom onset were 13 times less likely to experience progression, compared with PWH not prescribed tecovirimat within that window. In a matched cohort of 112 PWH, mpox disease progression occurred in 5.4% in an early tecovirimat group and in 26.8% in a late- or no-tecovirimat group, for a paired odds ratio of 13.00 (95% CI, 1.71-99.40; P = .002).

“Results of the present study suggest that tecovirimat treatment should be started early at the time of suspected mpox diagnosis in all PWH, especially in those with nonsuppressed HIV viremia or mucosal site involvement,” wrote a team led by Bruce Aldred, MD, of the Division of Infectious Diseases in the Department of Medicine at Emory University School of Medicine in Atlanta, in JAMA Internal Medicine. Early symptoms of mpox include skin rash and mucosal lesions, along with viral symptoms such as fever, headache, muscle aches, back pain, low energy, and swollen lymph nodes.

As of March 1 of last year, the United States reported more than 30,000 cases, while cases numbered more than 86,000 worldwide.

Despite a lack of effectiveness data in humans, tecovirimat was widely prescribed to PWH with mpox during the 2022 epidemic, which disproportionately affected PWH, particularly those with low CD4+ T-cell counts or severe mpox clinical manifestations who needed urgent therapy. Developed to treat smallpox, tecovirimat has antiviral activity against other orthopoxviruses, and has reduced mpox-related morbidity and mortality in animals.

Based on the animal data, approval was granted by the US Food and Drug Administration (FDA) for human mpox treatment. Dr. Aldred and colleagues undertook this cohort analysis in the absence of human data and with the postoutbreak decline in cases impeding recruitment to a full-scale clinical trial.

Study design

The preponderantly Black cohort included 112 PWH diagnosed with mpox at four Atlanta hospitals from June 1 to October 7, 2022. Patients were grouped in an early cohort receiving tecovirimat within 7 days of symptom onset or a no or late cohort (no tecovirimat or treatment more than 7 days after symptom onset. Multivariate logistic regression models identified factors associated with progression, defined as development of at least one severe CDC mpox criterion after symptom day 7.

The cohorts were then matched 1:1 using propensity scores based on the identified factors, and mpox disease progression was compared.

Of 112 PWH, 56 receive early tecovirimat and 56 received no or late treatment. In the early group, the median (interquartile range [IQR]) age was 35 (30-42) years; 54 individuals (96.4%) were cisgender men, 46 (82.1%) were Black, and 10 (17.9%) were, variously, White, American Indian, Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or of unknown race.

In the late- or no-tecovirimat group, the median (IQR) age was 36 (32-43) years; 54 (96.4%) were cisgender men, 49 (87.5%) were Black, and 7 (12.5%) were individuals of other or unknown race. Mpox disease progression occurred in 3 PWH in the early-tecovirimat group and 15 PWH (26.8%) in the late- or no-tecovirimat group.

Dr. Aldred and colleagues acknowledged that more research is needed to confirm the findings and cited several study limitations. These included the small sample size, the preponderance of Black participants, and the possibility that unmatched confounding variables could have led to the observation of fewer cases of severe disease in the early-tecovirimat cohort.

This study was supported by a grant from the Emory Center for AIDS Research. Coauthors reported grants from various institutes at the National Institutes of Health as well as from multiple pharmaceutical companies.

A new analysis supports using the smallpox antiviral tecovirimat (TPOXX/ST-246) in HIV patients showing the first symptoms of the human smallpox disease mpox (monkeypox), caused by the variola virus.

In a small prospective matched cohort analysis, people with HIV (PWH) and mpox disease who received tecovirimat within 7 days of symptom onset were 13 times less likely to experience progression, compared with PWH not prescribed tecovirimat within that window. In a matched cohort of 112 PWH, mpox disease progression occurred in 5.4% in an early tecovirimat group and in 26.8% in a late- or no-tecovirimat group, for a paired odds ratio of 13.00 (95% CI, 1.71-99.40; P = .002).

“Results of the present study suggest that tecovirimat treatment should be started early at the time of suspected mpox diagnosis in all PWH, especially in those with nonsuppressed HIV viremia or mucosal site involvement,” wrote a team led by Bruce Aldred, MD, of the Division of Infectious Diseases in the Department of Medicine at Emory University School of Medicine in Atlanta, in JAMA Internal Medicine. Early symptoms of mpox include skin rash and mucosal lesions, along with viral symptoms such as fever, headache, muscle aches, back pain, low energy, and swollen lymph nodes.

As of March 1 of last year, the United States reported more than 30,000 cases, while cases numbered more than 86,000 worldwide.

Despite a lack of effectiveness data in humans, tecovirimat was widely prescribed to PWH with mpox during the 2022 epidemic, which disproportionately affected PWH, particularly those with low CD4+ T-cell counts or severe mpox clinical manifestations who needed urgent therapy. Developed to treat smallpox, tecovirimat has antiviral activity against other orthopoxviruses, and has reduced mpox-related morbidity and mortality in animals.

Based on the animal data, approval was granted by the US Food and Drug Administration (FDA) for human mpox treatment. Dr. Aldred and colleagues undertook this cohort analysis in the absence of human data and with the postoutbreak decline in cases impeding recruitment to a full-scale clinical trial.

Study design

The preponderantly Black cohort included 112 PWH diagnosed with mpox at four Atlanta hospitals from June 1 to October 7, 2022. Patients were grouped in an early cohort receiving tecovirimat within 7 days of symptom onset or a no or late cohort (no tecovirimat or treatment more than 7 days after symptom onset. Multivariate logistic regression models identified factors associated with progression, defined as development of at least one severe CDC mpox criterion after symptom day 7.

The cohorts were then matched 1:1 using propensity scores based on the identified factors, and mpox disease progression was compared.

Of 112 PWH, 56 receive early tecovirimat and 56 received no or late treatment. In the early group, the median (interquartile range [IQR]) age was 35 (30-42) years; 54 individuals (96.4%) were cisgender men, 46 (82.1%) were Black, and 10 (17.9%) were, variously, White, American Indian, Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or of unknown race.

In the late- or no-tecovirimat group, the median (IQR) age was 36 (32-43) years; 54 (96.4%) were cisgender men, 49 (87.5%) were Black, and 7 (12.5%) were individuals of other or unknown race. Mpox disease progression occurred in 3 PWH in the early-tecovirimat group and 15 PWH (26.8%) in the late- or no-tecovirimat group.

Dr. Aldred and colleagues acknowledged that more research is needed to confirm the findings and cited several study limitations. These included the small sample size, the preponderance of Black participants, and the possibility that unmatched confounding variables could have led to the observation of fewer cases of severe disease in the early-tecovirimat cohort.

This study was supported by a grant from the Emory Center for AIDS Research. Coauthors reported grants from various institutes at the National Institutes of Health as well as from multiple pharmaceutical companies.

A new analysis supports using the smallpox antiviral tecovirimat (TPOXX/ST-246) in HIV patients showing the first symptoms of the human smallpox disease mpox (monkeypox), caused by the variola virus.

In a small prospective matched cohort analysis, people with HIV (PWH) and mpox disease who received tecovirimat within 7 days of symptom onset were 13 times less likely to experience progression, compared with PWH not prescribed tecovirimat within that window. In a matched cohort of 112 PWH, mpox disease progression occurred in 5.4% in an early tecovirimat group and in 26.8% in a late- or no-tecovirimat group, for a paired odds ratio of 13.00 (95% CI, 1.71-99.40; P = .002).

“Results of the present study suggest that tecovirimat treatment should be started early at the time of suspected mpox diagnosis in all PWH, especially in those with nonsuppressed HIV viremia or mucosal site involvement,” wrote a team led by Bruce Aldred, MD, of the Division of Infectious Diseases in the Department of Medicine at Emory University School of Medicine in Atlanta, in JAMA Internal Medicine. Early symptoms of mpox include skin rash and mucosal lesions, along with viral symptoms such as fever, headache, muscle aches, back pain, low energy, and swollen lymph nodes.

As of March 1 of last year, the United States reported more than 30,000 cases, while cases numbered more than 86,000 worldwide.

Despite a lack of effectiveness data in humans, tecovirimat was widely prescribed to PWH with mpox during the 2022 epidemic, which disproportionately affected PWH, particularly those with low CD4+ T-cell counts or severe mpox clinical manifestations who needed urgent therapy. Developed to treat smallpox, tecovirimat has antiviral activity against other orthopoxviruses, and has reduced mpox-related morbidity and mortality in animals.

Based on the animal data, approval was granted by the US Food and Drug Administration (FDA) for human mpox treatment. Dr. Aldred and colleagues undertook this cohort analysis in the absence of human data and with the postoutbreak decline in cases impeding recruitment to a full-scale clinical trial.

Study design

The preponderantly Black cohort included 112 PWH diagnosed with mpox at four Atlanta hospitals from June 1 to October 7, 2022. Patients were grouped in an early cohort receiving tecovirimat within 7 days of symptom onset or a no or late cohort (no tecovirimat or treatment more than 7 days after symptom onset. Multivariate logistic regression models identified factors associated with progression, defined as development of at least one severe CDC mpox criterion after symptom day 7.

The cohorts were then matched 1:1 using propensity scores based on the identified factors, and mpox disease progression was compared.

Of 112 PWH, 56 receive early tecovirimat and 56 received no or late treatment. In the early group, the median (interquartile range [IQR]) age was 35 (30-42) years; 54 individuals (96.4%) were cisgender men, 46 (82.1%) were Black, and 10 (17.9%) were, variously, White, American Indian, Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or of unknown race.

In the late- or no-tecovirimat group, the median (IQR) age was 36 (32-43) years; 54 (96.4%) were cisgender men, 49 (87.5%) were Black, and 7 (12.5%) were individuals of other or unknown race. Mpox disease progression occurred in 3 PWH in the early-tecovirimat group and 15 PWH (26.8%) in the late- or no-tecovirimat group.

Dr. Aldred and colleagues acknowledged that more research is needed to confirm the findings and cited several study limitations. These included the small sample size, the preponderance of Black participants, and the possibility that unmatched confounding variables could have led to the observation of fewer cases of severe disease in the early-tecovirimat cohort.

This study was supported by a grant from the Emory Center for AIDS Research. Coauthors reported grants from various institutes at the National Institutes of Health as well as from multiple pharmaceutical companies.

A resurgence of mpox this summer could be larger than last year’s caseload, the Centers for Disease Control and Prevention said in a warning to public health officials this week.

“The outbreak is not over,” the CDC alert stated, noting that springtime and summertime gatherings and festivals could lead to renewed virus spread. A new cluster of 13 cases is being investigated in Chicago, all among men, and four among people who recently traveled to New York City, New Orleans, or Mexico. 

Mpox, formerly called monkeypox, is a virus that causes a rash and sometimes flulike symptoms. It is most often transmitted through sexual contact, but it can also be spread in nonsexual ways that involve contact with skin lesions or with saliva or upper respiratory secretions like snot or mucus, the CDC says. Most cases in the United States have been among gay or bisexual men, men who have sex with men, and transgender people.

Last year, the U.S. government declared mpox a public health emergency as cases peaked at 460 per day in August, infecting more than 30,000 people and killing 42 people. Public health officials worked to quickly distribute vaccinations to people at high risk for contracting the virus. The CDC says 23% of people most at risk of getting mpox have been vaccinated.

The agency advises that people be vaccinated for mpox based on their potential exposure risk. Vaccination does not necessarily prevent infection but can lessen the severity of symptoms. Nine of the men who were recently infected in Chicago were fully vaccinated.

“It’s important to remember that vaccines, while incredibly helpful, are not our only way to reduce the risk of contracting mpox,” Richard Silvera, MD, MPH, of the department of infectious diseases at Icahn School of Medicine at Mount Sinai, New York, told ABC News. 

Other ways to reduce risk are “things like avoiding social and sexual contact if you have new skin lesions and asking your intimate contacts if they are experiencing symptoms or new skin changes,” Dr. Silvera said.

A version of this article first appeared on WebMD.com.

A resurgence of mpox this summer could be larger than last year’s caseload, the Centers for Disease Control and Prevention said in a warning to public health officials this week.

“The outbreak is not over,” the CDC alert stated, noting that springtime and summertime gatherings and festivals could lead to renewed virus spread. A new cluster of 13 cases is being investigated in Chicago, all among men, and four among people who recently traveled to New York City, New Orleans, or Mexico. 

Mpox, formerly called monkeypox, is a virus that causes a rash and sometimes flulike symptoms. It is most often transmitted through sexual contact, but it can also be spread in nonsexual ways that involve contact with skin lesions or with saliva or upper respiratory secretions like snot or mucus, the CDC says. Most cases in the United States have been among gay or bisexual men, men who have sex with men, and transgender people.

Last year, the U.S. government declared mpox a public health emergency as cases peaked at 460 per day in August, infecting more than 30,000 people and killing 42 people. Public health officials worked to quickly distribute vaccinations to people at high risk for contracting the virus. The CDC says 23% of people most at risk of getting mpox have been vaccinated.

The agency advises that people be vaccinated for mpox based on their potential exposure risk. Vaccination does not necessarily prevent infection but can lessen the severity of symptoms. Nine of the men who were recently infected in Chicago were fully vaccinated.

“It’s important to remember that vaccines, while incredibly helpful, are not our only way to reduce the risk of contracting mpox,” Richard Silvera, MD, MPH, of the department of infectious diseases at Icahn School of Medicine at Mount Sinai, New York, told ABC News. 

Other ways to reduce risk are “things like avoiding social and sexual contact if you have new skin lesions and asking your intimate contacts if they are experiencing symptoms or new skin changes,” Dr. Silvera said.

A version of this article first appeared on WebMD.com.

A resurgence of mpox this summer could be larger than last year’s caseload, the Centers for Disease Control and Prevention said in a warning to public health officials this week.

“The outbreak is not over,” the CDC alert stated, noting that springtime and summertime gatherings and festivals could lead to renewed virus spread. A new cluster of 13 cases is being investigated in Chicago, all among men, and four among people who recently traveled to New York City, New Orleans, or Mexico. 

Mpox, formerly called monkeypox, is a virus that causes a rash and sometimes flulike symptoms. It is most often transmitted through sexual contact, but it can also be spread in nonsexual ways that involve contact with skin lesions or with saliva or upper respiratory secretions like snot or mucus, the CDC says. Most cases in the United States have been among gay or bisexual men, men who have sex with men, and transgender people.

Last year, the U.S. government declared mpox a public health emergency as cases peaked at 460 per day in August, infecting more than 30,000 people and killing 42 people. Public health officials worked to quickly distribute vaccinations to people at high risk for contracting the virus. The CDC says 23% of people most at risk of getting mpox have been vaccinated.

The agency advises that people be vaccinated for mpox based on their potential exposure risk. Vaccination does not necessarily prevent infection but can lessen the severity of symptoms. Nine of the men who were recently infected in Chicago were fully vaccinated.

“It’s important to remember that vaccines, while incredibly helpful, are not our only way to reduce the risk of contracting mpox,” Richard Silvera, MD, MPH, of the department of infectious diseases at Icahn School of Medicine at Mount Sinai, New York, told ABC News. 

Other ways to reduce risk are “things like avoiding social and sexual contact if you have new skin lesions and asking your intimate contacts if they are experiencing symptoms or new skin changes,” Dr. Silvera said.

A version of this article first appeared on WebMD.com.

What do green monkeys, fruit bats, and python caves all have in common? All have been implicated in outbreaks as transmission sources of the rare but deadly Marburg virus. Marburg virus is in the same Filoviridae family of highly pathogenic RNA viruses as Ebola virus, and similarly can cause a rapidly progressive and fatal viral hemorrhagic fever.

In the first reported Marburg outbreak in 1967, laboratory workers in Marburg and Frankfurt, Germany, and in Belgrade, Yugoslavia, developed severe febrile illnesses with massive hemorrhage and multiorgan system dysfunction after contact with infected African green monkeys imported from Uganda. Since the first discovery of Marburg virus, there have been over 14 Marburg virus disease (MVD) outbreaks worldwide with nearly 600 cases and case fatality rates of 23%-90%.

The majority of MVD outbreaks have occurred in sub-Saharan Africa, and primarily in three African countries: Angola, the Democratic Republic of Congo, and Uganda. In sub-Saharan Africa, these sporadic outbreaks have had high case fatality rates (up to 80%-90%) and been linked to human exposure to the oral secretions or urinary/fecal droppings of Egyptian fruit bats (Rousettus aegyptiacus), the animal reservoir for Marburg virus. These exposures have primarily occurred among miners or tourists frequenting bat-infested mines or caves, including Uganda’s python cave, where Centers for Disease Control and Prevention investigators have conducted ecological studies on Marburg-infected bats. Person-to-person transmission occurs from direct contact with the blood or bodily fluids of an infected person or contact with a contaminated object (for example, unsterilized needles and syringes in a large nosocomial outbreak in Angola).

On April 6, 2023, the CDC issued a Health Advisory for U.S. clinicians and public health departments regarding two separate MVD outbreaks in Equatorial Guinea and Tanzania. These first-ever MVD outbreaks in both West and East African countries appear to be epidemiologically unrelated. As of March 24, 2023, in Equatorial Guinea, a total of 15 confirmed cases, including 11 deaths, and 23 probable cases, all deceased, have been identified in multiple districts since the outbreak declaration in February 2023. In Tanzania, a total of eight cases, including five deaths, have been reported among villagers in a northwest region since the outbreak declaration in March 2023. While so far cases in the Tanzania MVD outbreak have been epidemiologically linked, in Equatorial Guinea some cases have no identified epidemiological links, raising concern for ongoing community spread.

To date, no cases in these outbreaks have been reported in the United States or outside the affected countries. Overall, the risk of MVD in nonendemic countries, like the United States, is low but there is still a risk of importation. As of May 2, 2023, CDC has issued a Level 2 travel alert (practice enhanced precautions) for Marburg in Equatorial Guinea and a Level 1 travel watch (practice usual precautions) for Marburg in Tanzania. Travelers to these countries are advised to avoid nonessential travel to areas with active outbreaks and practice preventative measures, including avoiding contact with sick people, blood and bodily fluids, dead bodies, fruit bats, and nonhuman primates. International travelers returning to the United States from these countries are advised to self-monitor for Marburg symptoms during travel and for 21 days after country departure. Travelers who develop signs or symptoms of MVD should immediately self-isolate and contact their local health department or clinician.

So, how should clinicians manage such return travelers? In the setting of these new MVD outbreaks in sub-Saharan Africa, what do U.S. clinicians need to know? Clinicians should consider MVD in the differential diagnosis of ill patients with a compatible exposure history and clinical presentation. A detailed exposure history should be obtained to determine if patients have been to an area with an active MVD outbreak during their incubation period (in the past 21 days), had concerning epidemiologic risk factors (for example, presence at funerals, health care facilities, in mines/caves) while in the affected area, and/or had contact with a suspected or confirmed MVD case.

Clinical diagnosis of MVD is challenging as the initial dry symptoms of infection are nonspecific (fever, influenza-like illness, malaise, anorexia, etc.) and can resemble other febrile infectious illnesses. Similarly, presenting alternative or concurrent infections, particularly in febrile return travelers, include malaria, Lassa fever, typhoid, and measles. From these nonspecific symptoms, patients with MVD can then progress to the more severe wet symptoms (for example, vomiting, diarrhea, and bleeding). Common clinical features of MVD have been described based on the clinical presentation and course of cases in MVD outbreaks. Notably, in the original Marburg outbreak, maculopapular rash and conjunctival injection were early patient symptoms and most patient deaths occurred during the second week of illness progression.

Supportive care, including aggressive fluid replacement, is the mainstay of therapy for MVD. Currently, there are no Food and Drug Administration–approved antiviral treatments or vaccines for Marburg virus. Despite their viral similarities, vaccines against Ebola virus have not been shown to be protective against Marburg virus. Marburg virus vaccine development is ongoing, with a few promising candidate vaccines in early phase 1 and 2 clinical trials. In 2022, in response to MVD outbreaks in Ghana and Guinea, the World Health Organization convened an international Marburg virus vaccine consortium which is working to promote global research collaboration for more rapid vaccine development.

In the absence of definitive therapies, early identification of patients with suspected MVD is critical for preventing the spread of infection to close contacts. Like Ebola virus–infected patients, only symptomatic MVD patients are infectious and all patients with suspected MVD should be isolated in a private room and cared for in accordance with infection control procedures. As MVD is a nationally notifiable disease, suspected cases should be reported to local or state health departments as per jurisdictional requirements. Clinicians should also consult with their local or state health department and CDC for guidance on testing patients with suspected MVD and consider prompt evaluation for other infectious etiologies in the patient’s differential diagnosis. Comprehensive guidance for clinicians on screening and diagnosing patients with MVD is available on the CDC website at https://www.cdc.gov/vhf/marburg/index.html.

Dr. Appiah (she/her) is a medical epidemiologist in the division of global migration and quarantine at the CDC. Dr. Appiah holds adjunct faculty appointment in the division of infectious diseases at Emory University, Atlanta. She also holds a commission in the U.S. Public Health Service and is a resident advisor, Uganda, U.S. President’s Malaria Initiative, at the CDC.

What do green monkeys, fruit bats, and python caves all have in common? All have been implicated in outbreaks as transmission sources of the rare but deadly Marburg virus. Marburg virus is in the same Filoviridae family of highly pathogenic RNA viruses as Ebola virus, and similarly can cause a rapidly progressive and fatal viral hemorrhagic fever.

In the first reported Marburg outbreak in 1967, laboratory workers in Marburg and Frankfurt, Germany, and in Belgrade, Yugoslavia, developed severe febrile illnesses with massive hemorrhage and multiorgan system dysfunction after contact with infected African green monkeys imported from Uganda. Since the first discovery of Marburg virus, there have been over 14 Marburg virus disease (MVD) outbreaks worldwide with nearly 600 cases and case fatality rates of 23%-90%.

The majority of MVD outbreaks have occurred in sub-Saharan Africa, and primarily in three African countries: Angola, the Democratic Republic of Congo, and Uganda. In sub-Saharan Africa, these sporadic outbreaks have had high case fatality rates (up to 80%-90%) and been linked to human exposure to the oral secretions or urinary/fecal droppings of Egyptian fruit bats (Rousettus aegyptiacus), the animal reservoir for Marburg virus. These exposures have primarily occurred among miners or tourists frequenting bat-infested mines or caves, including Uganda’s python cave, where Centers for Disease Control and Prevention investigators have conducted ecological studies on Marburg-infected bats. Person-to-person transmission occurs from direct contact with the blood or bodily fluids of an infected person or contact with a contaminated object (for example, unsterilized needles and syringes in a large nosocomial outbreak in Angola).

On April 6, 2023, the CDC issued a Health Advisory for U.S. clinicians and public health departments regarding two separate MVD outbreaks in Equatorial Guinea and Tanzania. These first-ever MVD outbreaks in both West and East African countries appear to be epidemiologically unrelated. As of March 24, 2023, in Equatorial Guinea, a total of 15 confirmed cases, including 11 deaths, and 23 probable cases, all deceased, have been identified in multiple districts since the outbreak declaration in February 2023. In Tanzania, a total of eight cases, including five deaths, have been reported among villagers in a northwest region since the outbreak declaration in March 2023. While so far cases in the Tanzania MVD outbreak have been epidemiologically linked, in Equatorial Guinea some cases have no identified epidemiological links, raising concern for ongoing community spread.

To date, no cases in these outbreaks have been reported in the United States or outside the affected countries. Overall, the risk of MVD in nonendemic countries, like the United States, is low but there is still a risk of importation. As of May 2, 2023, CDC has issued a Level 2 travel alert (practice enhanced precautions) for Marburg in Equatorial Guinea and a Level 1 travel watch (practice usual precautions) for Marburg in Tanzania. Travelers to these countries are advised to avoid nonessential travel to areas with active outbreaks and practice preventative measures, including avoiding contact with sick people, blood and bodily fluids, dead bodies, fruit bats, and nonhuman primates. International travelers returning to the United States from these countries are advised to self-monitor for Marburg symptoms during travel and for 21 days after country departure. Travelers who develop signs or symptoms of MVD should immediately self-isolate and contact their local health department or clinician.

So, how should clinicians manage such return travelers? In the setting of these new MVD outbreaks in sub-Saharan Africa, what do U.S. clinicians need to know? Clinicians should consider MVD in the differential diagnosis of ill patients with a compatible exposure history and clinical presentation. A detailed exposure history should be obtained to determine if patients have been to an area with an active MVD outbreak during their incubation period (in the past 21 days), had concerning epidemiologic risk factors (for example, presence at funerals, health care facilities, in mines/caves) while in the affected area, and/or had contact with a suspected or confirmed MVD case.

Clinical diagnosis of MVD is challenging as the initial dry symptoms of infection are nonspecific (fever, influenza-like illness, malaise, anorexia, etc.) and can resemble other febrile infectious illnesses. Similarly, presenting alternative or concurrent infections, particularly in febrile return travelers, include malaria, Lassa fever, typhoid, and measles. From these nonspecific symptoms, patients with MVD can then progress to the more severe wet symptoms (for example, vomiting, diarrhea, and bleeding). Common clinical features of MVD have been described based on the clinical presentation and course of cases in MVD outbreaks. Notably, in the original Marburg outbreak, maculopapular rash and conjunctival injection were early patient symptoms and most patient deaths occurred during the second week of illness progression.

Supportive care, including aggressive fluid replacement, is the mainstay of therapy for MVD. Currently, there are no Food and Drug Administration–approved antiviral treatments or vaccines for Marburg virus. Despite their viral similarities, vaccines against Ebola virus have not been shown to be protective against Marburg virus. Marburg virus vaccine development is ongoing, with a few promising candidate vaccines in early phase 1 and 2 clinical trials. In 2022, in response to MVD outbreaks in Ghana and Guinea, the World Health Organization convened an international Marburg virus vaccine consortium which is working to promote global research collaboration for more rapid vaccine development.

In the absence of definitive therapies, early identification of patients with suspected MVD is critical for preventing the spread of infection to close contacts. Like Ebola virus–infected patients, only symptomatic MVD patients are infectious and all patients with suspected MVD should be isolated in a private room and cared for in accordance with infection control procedures. As MVD is a nationally notifiable disease, suspected cases should be reported to local or state health departments as per jurisdictional requirements. Clinicians should also consult with their local or state health department and CDC for guidance on testing patients with suspected MVD and consider prompt evaluation for other infectious etiologies in the patient’s differential diagnosis. Comprehensive guidance for clinicians on screening and diagnosing patients with MVD is available on the CDC website at https://www.cdc.gov/vhf/marburg/index.html.

Dr. Appiah (she/her) is a medical epidemiologist in the division of global migration and quarantine at the CDC. Dr. Appiah holds adjunct faculty appointment in the division of infectious diseases at Emory University, Atlanta. She also holds a commission in the U.S. Public Health Service and is a resident advisor, Uganda, U.S. President’s Malaria Initiative, at the CDC.

What do green monkeys, fruit bats, and python caves all have in common? All have been implicated in outbreaks as transmission sources of the rare but deadly Marburg virus. Marburg virus is in the same Filoviridae family of highly pathogenic RNA viruses as Ebola virus, and similarly can cause a rapidly progressive and fatal viral hemorrhagic fever.

In the first reported Marburg outbreak in 1967, laboratory workers in Marburg and Frankfurt, Germany, and in Belgrade, Yugoslavia, developed severe febrile illnesses with massive hemorrhage and multiorgan system dysfunction after contact with infected African green monkeys imported from Uganda. Since the first discovery of Marburg virus, there have been over 14 Marburg virus disease (MVD) outbreaks worldwide with nearly 600 cases and case fatality rates of 23%-90%.

The majority of MVD outbreaks have occurred in sub-Saharan Africa, and primarily in three African countries: Angola, the Democratic Republic of Congo, and Uganda. In sub-Saharan Africa, these sporadic outbreaks have had high case fatality rates (up to 80%-90%) and been linked to human exposure to the oral secretions or urinary/fecal droppings of Egyptian fruit bats (Rousettus aegyptiacus), the animal reservoir for Marburg virus. These exposures have primarily occurred among miners or tourists frequenting bat-infested mines or caves, including Uganda’s python cave, where Centers for Disease Control and Prevention investigators have conducted ecological studies on Marburg-infected bats. Person-to-person transmission occurs from direct contact with the blood or bodily fluids of an infected person or contact with a contaminated object (for example, unsterilized needles and syringes in a large nosocomial outbreak in Angola).

On April 6, 2023, the CDC issued a Health Advisory for U.S. clinicians and public health departments regarding two separate MVD outbreaks in Equatorial Guinea and Tanzania. These first-ever MVD outbreaks in both West and East African countries appear to be epidemiologically unrelated. As of March 24, 2023, in Equatorial Guinea, a total of 15 confirmed cases, including 11 deaths, and 23 probable cases, all deceased, have been identified in multiple districts since the outbreak declaration in February 2023. In Tanzania, a total of eight cases, including five deaths, have been reported among villagers in a northwest region since the outbreak declaration in March 2023. While so far cases in the Tanzania MVD outbreak have been epidemiologically linked, in Equatorial Guinea some cases have no identified epidemiological links, raising concern for ongoing community spread.

To date, no cases in these outbreaks have been reported in the United States or outside the affected countries. Overall, the risk of MVD in nonendemic countries, like the United States, is low but there is still a risk of importation. As of May 2, 2023, CDC has issued a Level 2 travel alert (practice enhanced precautions) for Marburg in Equatorial Guinea and a Level 1 travel watch (practice usual precautions) for Marburg in Tanzania. Travelers to these countries are advised to avoid nonessential travel to areas with active outbreaks and practice preventative measures, including avoiding contact with sick people, blood and bodily fluids, dead bodies, fruit bats, and nonhuman primates. International travelers returning to the United States from these countries are advised to self-monitor for Marburg symptoms during travel and for 21 days after country departure. Travelers who develop signs or symptoms of MVD should immediately self-isolate and contact their local health department or clinician.

So, how should clinicians manage such return travelers? In the setting of these new MVD outbreaks in sub-Saharan Africa, what do U.S. clinicians need to know? Clinicians should consider MVD in the differential diagnosis of ill patients with a compatible exposure history and clinical presentation. A detailed exposure history should be obtained to determine if patients have been to an area with an active MVD outbreak during their incubation period (in the past 21 days), had concerning epidemiologic risk factors (for example, presence at funerals, health care facilities, in mines/caves) while in the affected area, and/or had contact with a suspected or confirmed MVD case.

Clinical diagnosis of MVD is challenging as the initial dry symptoms of infection are nonspecific (fever, influenza-like illness, malaise, anorexia, etc.) and can resemble other febrile infectious illnesses. Similarly, presenting alternative or concurrent infections, particularly in febrile return travelers, include malaria, Lassa fever, typhoid, and measles. From these nonspecific symptoms, patients with MVD can then progress to the more severe wet symptoms (for example, vomiting, diarrhea, and bleeding). Common clinical features of MVD have been described based on the clinical presentation and course of cases in MVD outbreaks. Notably, in the original Marburg outbreak, maculopapular rash and conjunctival injection were early patient symptoms and most patient deaths occurred during the second week of illness progression.

Supportive care, including aggressive fluid replacement, is the mainstay of therapy for MVD. Currently, there are no Food and Drug Administration–approved antiviral treatments or vaccines for Marburg virus. Despite their viral similarities, vaccines against Ebola virus have not been shown to be protective against Marburg virus. Marburg virus vaccine development is ongoing, with a few promising candidate vaccines in early phase 1 and 2 clinical trials. In 2022, in response to MVD outbreaks in Ghana and Guinea, the World Health Organization convened an international Marburg virus vaccine consortium which is working to promote global research collaboration for more rapid vaccine development.

In the absence of definitive therapies, early identification of patients with suspected MVD is critical for preventing the spread of infection to close contacts. Like Ebola virus–infected patients, only symptomatic MVD patients are infectious and all patients with suspected MVD should be isolated in a private room and cared for in accordance with infection control procedures. As MVD is a nationally notifiable disease, suspected cases should be reported to local or state health departments as per jurisdictional requirements. Clinicians should also consult with their local or state health department and CDC for guidance on testing patients with suspected MVD and consider prompt evaluation for other infectious etiologies in the patient’s differential diagnosis. Comprehensive guidance for clinicians on screening and diagnosing patients with MVD is available on the CDC website at https://www.cdc.gov/vhf/marburg/index.html.

Dr. Appiah (she/her) is a medical epidemiologist in the division of global migration and quarantine at the CDC. Dr. Appiah holds adjunct faculty appointment in the division of infectious diseases at Emory University, Atlanta. She also holds a commission in the U.S. Public Health Service and is a resident advisor, Uganda, U.S. President’s Malaria Initiative, at the CDC.

Clinicians in the United States are reporting more cases of invasive group A streptococcal infection (iGAS) in children, according to an alert from the Centers for Disease Control and Prevention. These infections are rare but can be deadly, and they can affect adults as well as children.

Health care providers should consider this bacterial infection as a possible cause of severe illness in children and adults, including those with recent or co-occurring viral respiratory infections, the agency advised in a Dec. 22 alert.

In some cases, iGAS manifests as persistent or worsening symptoms after a patient with a known viral infection initially starts to show signs of improvement, according to the agency.

In November, the CDC was notified about a possible increase in cases of pediatric iGAS at a hospital in Colorado. Since then, two surveillance systems – the Infectious Diseases Society of America’s Emerging Infections Network and the CDC’s Active Bacterial Core Surveillance System – have detected potential increases in pediatric iGAS cases in other states.

The uptick has coincided with “increased circulation of respiratory syncytial virus (RSV), influenza viruses, SARS-CoV-2, and other respiratory viruses,” the advisory stated. “While the overall number of cases has remained relatively low and iGAS infections remain rare in children, [the] CDC is investigating these reports.”
 

Not just strep throat

Group A Streptococcus bacteria can cause strep throat and infections in skin and soft tissue. The pathogens also can lead to uncommon but severe diseases, such as sepsis, streptococcal toxic shock syndrome, and necrotizing fasciitis, according to the CDC. The severe illnesses “are associated with high mortality rates and require immediate treatment, including appropriate antibiotic therapy,” the agency said.

Groups at higher risk for iGAS include people aged 65 years or older, American Indian and Alaska Native populations, residents of long-term care facilities, those with wounds or skin disease, people who inject drugs, and people experiencing homelessness.

People with medical conditions such as diabetes, cancer, immunosuppression, and chronic kidney, heart, or respiratory disease also are at increased risk.

Invasive strep A infections initially decreased during the COVID-19 pandemic amid measures to reduce the spread of disease, such as masking and social distancing. But since September, monthly cases have exceeded those in 2020 and 2021. “It is too early to determine whether this rise is beyond what would be expected for pre-COVID” seasonal patterns, the CDC said.
 

Recommendations

Because iGAS can occur after the flu or chickenpox, health care providers should offer influenza and varicella vaccinations to all eligible people who are not up to date with their vaccines.

In addition, clinicians should educate patients about symptoms of iGAS that require urgent medical attention, including necrotizing fasciitis, cellulitis, and toxic shock syndrome.

They also should obtain cultures for suspected cases of iGAS as clinically indicated, follow guidelines for the diagnosis and treatment of strep throat, and be aware of alternative ways to treat strep throat in children amid a shortage of amoxicillin suspension.

Researchers have reported more cases of iGAS in the United Kingdom this year, as well. According to the UK Health Security Agency, 74 deaths, including 16 children, in England have been attributed to iGAS since September.

“We know that this is concerning for parents, but I want to stress that while we are seeing an increase in cases in children, this remains very uncommon,” UKHSA Deputy Director Colin Brown said in a news release. “There are lots of winter bugs circulating that can make your child feel unwell that mostly aren’t cause for alarm. However, make sure you talk to a health professional if your child is getting worse after a bout of scarlet fever, a sore throat, or respiratory infection.”

A fever that doesn’t resolve, dehydration, extreme tiredness, and difficulty breathing are signs to watch out for, Dr. Brown said.

A version of this article first appeared on Medscape.com.

Clinicians in the United States are reporting more cases of invasive group A streptococcal infection (iGAS) in children, according to an alert from the Centers for Disease Control and Prevention. These infections are rare but can be deadly, and they can affect adults as well as children.

Health care providers should consider this bacterial infection as a possible cause of severe illness in children and adults, including those with recent or co-occurring viral respiratory infections, the agency advised in a Dec. 22 alert.

In some cases, iGAS manifests as persistent or worsening symptoms after a patient with a known viral infection initially starts to show signs of improvement, according to the agency.

In November, the CDC was notified about a possible increase in cases of pediatric iGAS at a hospital in Colorado. Since then, two surveillance systems – the Infectious Diseases Society of America’s Emerging Infections Network and the CDC’s Active Bacterial Core Surveillance System – have detected potential increases in pediatric iGAS cases in other states.

The uptick has coincided with “increased circulation of respiratory syncytial virus (RSV), influenza viruses, SARS-CoV-2, and other respiratory viruses,” the advisory stated. “While the overall number of cases has remained relatively low and iGAS infections remain rare in children, [the] CDC is investigating these reports.”
 

Not just strep throat

Group A Streptococcus bacteria can cause strep throat and infections in skin and soft tissue. The pathogens also can lead to uncommon but severe diseases, such as sepsis, streptococcal toxic shock syndrome, and necrotizing fasciitis, according to the CDC. The severe illnesses “are associated with high mortality rates and require immediate treatment, including appropriate antibiotic therapy,” the agency said.

Groups at higher risk for iGAS include people aged 65 years or older, American Indian and Alaska Native populations, residents of long-term care facilities, those with wounds or skin disease, people who inject drugs, and people experiencing homelessness.

People with medical conditions such as diabetes, cancer, immunosuppression, and chronic kidney, heart, or respiratory disease also are at increased risk.

Invasive strep A infections initially decreased during the COVID-19 pandemic amid measures to reduce the spread of disease, such as masking and social distancing. But since September, monthly cases have exceeded those in 2020 and 2021. “It is too early to determine whether this rise is beyond what would be expected for pre-COVID” seasonal patterns, the CDC said.
 

Recommendations

Because iGAS can occur after the flu or chickenpox, health care providers should offer influenza and varicella vaccinations to all eligible people who are not up to date with their vaccines.

In addition, clinicians should educate patients about symptoms of iGAS that require urgent medical attention, including necrotizing fasciitis, cellulitis, and toxic shock syndrome.

They also should obtain cultures for suspected cases of iGAS as clinically indicated, follow guidelines for the diagnosis and treatment of strep throat, and be aware of alternative ways to treat strep throat in children amid a shortage of amoxicillin suspension.

Researchers have reported more cases of iGAS in the United Kingdom this year, as well. According to the UK Health Security Agency, 74 deaths, including 16 children, in England have been attributed to iGAS since September.

“We know that this is concerning for parents, but I want to stress that while we are seeing an increase in cases in children, this remains very uncommon,” UKHSA Deputy Director Colin Brown said in a news release. “There are lots of winter bugs circulating that can make your child feel unwell that mostly aren’t cause for alarm. However, make sure you talk to a health professional if your child is getting worse after a bout of scarlet fever, a sore throat, or respiratory infection.”

A fever that doesn’t resolve, dehydration, extreme tiredness, and difficulty breathing are signs to watch out for, Dr. Brown said.

A version of this article first appeared on Medscape.com.

Clinicians in the United States are reporting more cases of invasive group A streptococcal infection (iGAS) in children, according to an alert from the Centers for Disease Control and Prevention. These infections are rare but can be deadly, and they can affect adults as well as children.

Health care providers should consider this bacterial infection as a possible cause of severe illness in children and adults, including those with recent or co-occurring viral respiratory infections, the agency advised in a Dec. 22 alert.

In some cases, iGAS manifests as persistent or worsening symptoms after a patient with a known viral infection initially starts to show signs of improvement, according to the agency.

In November, the CDC was notified about a possible increase in cases of pediatric iGAS at a hospital in Colorado. Since then, two surveillance systems – the Infectious Diseases Society of America’s Emerging Infections Network and the CDC’s Active Bacterial Core Surveillance System – have detected potential increases in pediatric iGAS cases in other states.

The uptick has coincided with “increased circulation of respiratory syncytial virus (RSV), influenza viruses, SARS-CoV-2, and other respiratory viruses,” the advisory stated. “While the overall number of cases has remained relatively low and iGAS infections remain rare in children, [the] CDC is investigating these reports.”
 

Not just strep throat

Group A Streptococcus bacteria can cause strep throat and infections in skin and soft tissue. The pathogens also can lead to uncommon but severe diseases, such as sepsis, streptococcal toxic shock syndrome, and necrotizing fasciitis, according to the CDC. The severe illnesses “are associated with high mortality rates and require immediate treatment, including appropriate antibiotic therapy,” the agency said.

Groups at higher risk for iGAS include people aged 65 years or older, American Indian and Alaska Native populations, residents of long-term care facilities, those with wounds or skin disease, people who inject drugs, and people experiencing homelessness.

People with medical conditions such as diabetes, cancer, immunosuppression, and chronic kidney, heart, or respiratory disease also are at increased risk.

Invasive strep A infections initially decreased during the COVID-19 pandemic amid measures to reduce the spread of disease, such as masking and social distancing. But since September, monthly cases have exceeded those in 2020 and 2021. “It is too early to determine whether this rise is beyond what would be expected for pre-COVID” seasonal patterns, the CDC said.
 

Recommendations

Because iGAS can occur after the flu or chickenpox, health care providers should offer influenza and varicella vaccinations to all eligible people who are not up to date with their vaccines.

In addition, clinicians should educate patients about symptoms of iGAS that require urgent medical attention, including necrotizing fasciitis, cellulitis, and toxic shock syndrome.

They also should obtain cultures for suspected cases of iGAS as clinically indicated, follow guidelines for the diagnosis and treatment of strep throat, and be aware of alternative ways to treat strep throat in children amid a shortage of amoxicillin suspension.

Researchers have reported more cases of iGAS in the United Kingdom this year, as well. According to the UK Health Security Agency, 74 deaths, including 16 children, in England have been attributed to iGAS since September.

“We know that this is concerning for parents, but I want to stress that while we are seeing an increase in cases in children, this remains very uncommon,” UKHSA Deputy Director Colin Brown said in a news release. “There are lots of winter bugs circulating that can make your child feel unwell that mostly aren’t cause for alarm. However, make sure you talk to a health professional if your child is getting worse after a bout of scarlet fever, a sore throat, or respiratory infection.”

A fever that doesn’t resolve, dehydration, extreme tiredness, and difficulty breathing are signs to watch out for, Dr. Brown said.

A version of this article first appeared on Medscape.com.

Monkeypox virus infections in children and adolescents in the United States are rare, and young patients with known infections have all recovered, according to a study from the Centers for Disease Control and Prevention.

In addition, evidence suggests that secondary transmission in schools or childcare facilities may be unlikely.

The study was the first comprehensive study on the impact of monkeypox on children during the 2022 outbreak, according to a statement emailed to this news organization from the California Department of Public Health, one of the state health departments that partnered with the CDC to share information.

News of low infection rates and relatively mild disease was welcome to clinicians, who had braced for severe findings on the basis of sparse prior data, according to Peter Chin-Hong, MD, a professor of medicine and an infectious diseases physician at the University of California, San Francisco.

“We were on heightened alert that kids may do poorly,” said Dr. Chin-Hong, who was not involved in the study but who cared for monkeypox patients during the outbreak. “I think this study is reassuring.

“The other silver lining about it is that most of the kids got infected in the household setting from ways that you would expect them to get [infected],” Dr. Chin-Hong said in an interview.

However, Black and Hispanic children were more likely to contract the disease, underscoring troubling inequities.

“Early on, individuals of color were much less likely to be able to successfully access vaccination,” said first author Ian Hennessee, PhD, MPH, an epidemic intelligence service officer with the CDC and a member of the Special Case Investigation Unit of the Multinational Monkeypox Response Team at the CDC. “We think those kinds of structural inequities really trickled down towards the children and adolescents that have been affected by this outbreak.”

The study was published  in Morbidity and Mortality Weekly Report.
 

A nationwide look at the data

The researchers discussed 83 children and adolescents with monkeypox who came to the CDC’s attention between May 17 and Sept. 24, 2022.

The 83 cases represent 0.3% of the 25,038 reported monkeypox cases in the United States over that period. Of the 28 children aged 12 years or younger, 18 (64%) were boys. Sixteen children were younger than 4 years.

Exposure data were available for 20 (71%) of those aged 0-12. In that group, 19 were exposed at home; 17 cases were due to routine skin-to-skin contact with a household caregiver; and one case was suspected to be caused by fomites (such as a shared towel). Exposure information was unavailable for the remaining case.

Most of the children experienced lesions on the trunk. No lesions were anogenital. Two patients in the youngest age group were hospitalized because of widespread rash that involved the eyelids, and a patient in the 5- to 12-year-old group was hospitalized because of periorbital cellulitis and conjunctivitis.

Among those aged 13-17, there were 55 cases. Of these patients, 89% were boys. Exposure data were available for 35 (64%). In 32 of these patients, the infection occurred from presumed sexual contact. Twenty-three of those adolescents reported male-to-male sexual contact. No case was found to be connected with sexual abuse.

Lesions in the adolescents were mostly truncal or anogenital. Six in this group were hospitalized, and all of them recovered. One adolescent was found to be HIV positive.

Black and Hispanic children accounted for 47% and 35% of all cases, respectively.

Eleven percent of all the children and adolescents were hospitalized, and none received intensive care.

Treatments, when given, included the antiviral drug tecovirimat, intravenous vaccinia immune globulin, and topical trifluridine. There were no deaths.

Ten symptomatic patients attended school or daycare. Among these patients, no secondary transmissions were found to have occurred. Some contacts were offered the JYNNEOS monkeypox vaccine as postexposure prophylaxis.

Limitations of the study included potentially overlooked cases. Data were collected through routine surveillance, children frequently experience rashes, and access to testing has been a challenge, Dr. Hennessee explained.

In addition, data on exposure characteristics were missing for some children.
 

Inequities and the risks of being judged

The outbreak in the United States has eased in recent months. However, though uncommon in children, monkeypox has affected some racial groups disproportionately.

“Especially in the later course of the outbreak, the majority of cases were among Black and Hispanic individuals,” said co-author Rachel E. Harold, MD, an infectious diseases specialist and supervisory medical officer with the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STDs, and TB Administration.

“Unfortunately, the pediatric cases do reflect the outbreak overall,” she told this news organization.

Dr. Harold noted there have been efforts in D.C. and other jurisdictions, as well as by the White House monkeypox response team, to reach populations at greatest risk and that they were “really trying to make vaccine available to people of color.”

Vaccination clinics often popped up in unexpected locations at short notice, and that made it hard for some people to get to them, Dr. Chin-Hong pointed out.

Another factor was “the public aspect of accessing diagnostics and vaccines and the way that that’s linked to potential judgment or sexual risk,” he added.

“Not everybody’s out,” Dr. Chin-Hong said, referring to members of the LGBTQ community. “In many communities of color, going to get a test or going to get a vaccine essentially means that you’re out.”

For clinicians who suspect monkeypox in a child, Dr. Harold suggests keeping a broad differential diagnosis, looking for an epidemiologic link, and contacting the CDC for assistance. Infected children should be encouraged to avoid touching their own eyes or mucous membranes, she added.

In addition, she said, tecovirimat is a reasonable treatment and is well tolerated by pediatric monkeypox patients with eczema, an underlying condition that could lead to severe disease.

For infected caregivers, Dr. Hennessee said, measures to prevent infecting children at home include isolation, contact precautions, and in some cases, postexposure prophylaxis via vaccination.

For sexually active adolescents, he advised that clinicians offer vaccination, education on sexual health, and testing for HIV and other sexually transmitted infections.

“It’s important to remember that adolescents may be sexually active, and clinicians should do a thorough and nonjudgmental sexual history,” Dr. Harold added. “That is always true, but especially if there is concern for [monkeypox].”

Dr. Hennessee, Dr. Chin-Hong, and Dr. Harold have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Monkeypox virus infections in children and adolescents in the United States are rare, and young patients with known infections have all recovered, according to a study from the Centers for Disease Control and Prevention.

In addition, evidence suggests that secondary transmission in schools or childcare facilities may be unlikely.

The study was the first comprehensive study on the impact of monkeypox on children during the 2022 outbreak, according to a statement emailed to this news organization from the California Department of Public Health, one of the state health departments that partnered with the CDC to share information.

News of low infection rates and relatively mild disease was welcome to clinicians, who had braced for severe findings on the basis of sparse prior data, according to Peter Chin-Hong, MD, a professor of medicine and an infectious diseases physician at the University of California, San Francisco.

“We were on heightened alert that kids may do poorly,” said Dr. Chin-Hong, who was not involved in the study but who cared for monkeypox patients during the outbreak. “I think this study is reassuring.

“The other silver lining about it is that most of the kids got infected in the household setting from ways that you would expect them to get [infected],” Dr. Chin-Hong said in an interview.

However, Black and Hispanic children were more likely to contract the disease, underscoring troubling inequities.

“Early on, individuals of color were much less likely to be able to successfully access vaccination,” said first author Ian Hennessee, PhD, MPH, an epidemic intelligence service officer with the CDC and a member of the Special Case Investigation Unit of the Multinational Monkeypox Response Team at the CDC. “We think those kinds of structural inequities really trickled down towards the children and adolescents that have been affected by this outbreak.”

The study was published  in Morbidity and Mortality Weekly Report.
 

A nationwide look at the data

The researchers discussed 83 children and adolescents with monkeypox who came to the CDC’s attention between May 17 and Sept. 24, 2022.

The 83 cases represent 0.3% of the 25,038 reported monkeypox cases in the United States over that period. Of the 28 children aged 12 years or younger, 18 (64%) were boys. Sixteen children were younger than 4 years.

Exposure data were available for 20 (71%) of those aged 0-12. In that group, 19 were exposed at home; 17 cases were due to routine skin-to-skin contact with a household caregiver; and one case was suspected to be caused by fomites (such as a shared towel). Exposure information was unavailable for the remaining case.

Most of the children experienced lesions on the trunk. No lesions were anogenital. Two patients in the youngest age group were hospitalized because of widespread rash that involved the eyelids, and a patient in the 5- to 12-year-old group was hospitalized because of periorbital cellulitis and conjunctivitis.

Among those aged 13-17, there were 55 cases. Of these patients, 89% were boys. Exposure data were available for 35 (64%). In 32 of these patients, the infection occurred from presumed sexual contact. Twenty-three of those adolescents reported male-to-male sexual contact. No case was found to be connected with sexual abuse.

Lesions in the adolescents were mostly truncal or anogenital. Six in this group were hospitalized, and all of them recovered. One adolescent was found to be HIV positive.

Black and Hispanic children accounted for 47% and 35% of all cases, respectively.

Eleven percent of all the children and adolescents were hospitalized, and none received intensive care.

Treatments, when given, included the antiviral drug tecovirimat, intravenous vaccinia immune globulin, and topical trifluridine. There were no deaths.

Ten symptomatic patients attended school or daycare. Among these patients, no secondary transmissions were found to have occurred. Some contacts were offered the JYNNEOS monkeypox vaccine as postexposure prophylaxis.

Limitations of the study included potentially overlooked cases. Data were collected through routine surveillance, children frequently experience rashes, and access to testing has been a challenge, Dr. Hennessee explained.

In addition, data on exposure characteristics were missing for some children.
 

Inequities and the risks of being judged

The outbreak in the United States has eased in recent months. However, though uncommon in children, monkeypox has affected some racial groups disproportionately.

“Especially in the later course of the outbreak, the majority of cases were among Black and Hispanic individuals,” said co-author Rachel E. Harold, MD, an infectious diseases specialist and supervisory medical officer with the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STDs, and TB Administration.

“Unfortunately, the pediatric cases do reflect the outbreak overall,” she told this news organization.

Dr. Harold noted there have been efforts in D.C. and other jurisdictions, as well as by the White House monkeypox response team, to reach populations at greatest risk and that they were “really trying to make vaccine available to people of color.”

Vaccination clinics often popped up in unexpected locations at short notice, and that made it hard for some people to get to them, Dr. Chin-Hong pointed out.

Another factor was “the public aspect of accessing diagnostics and vaccines and the way that that’s linked to potential judgment or sexual risk,” he added.

“Not everybody’s out,” Dr. Chin-Hong said, referring to members of the LGBTQ community. “In many communities of color, going to get a test or going to get a vaccine essentially means that you’re out.”

For clinicians who suspect monkeypox in a child, Dr. Harold suggests keeping a broad differential diagnosis, looking for an epidemiologic link, and contacting the CDC for assistance. Infected children should be encouraged to avoid touching their own eyes or mucous membranes, she added.

In addition, she said, tecovirimat is a reasonable treatment and is well tolerated by pediatric monkeypox patients with eczema, an underlying condition that could lead to severe disease.

For infected caregivers, Dr. Hennessee said, measures to prevent infecting children at home include isolation, contact precautions, and in some cases, postexposure prophylaxis via vaccination.

For sexually active adolescents, he advised that clinicians offer vaccination, education on sexual health, and testing for HIV and other sexually transmitted infections.

“It’s important to remember that adolescents may be sexually active, and clinicians should do a thorough and nonjudgmental sexual history,” Dr. Harold added. “That is always true, but especially if there is concern for [monkeypox].”

Dr. Hennessee, Dr. Chin-Hong, and Dr. Harold have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Monkeypox virus infections in children and adolescents in the United States are rare, and young patients with known infections have all recovered, according to a study from the Centers for Disease Control and Prevention.

In addition, evidence suggests that secondary transmission in schools or childcare facilities may be unlikely.

The study was the first comprehensive study on the impact of monkeypox on children during the 2022 outbreak, according to a statement emailed to this news organization from the California Department of Public Health, one of the state health departments that partnered with the CDC to share information.

News of low infection rates and relatively mild disease was welcome to clinicians, who had braced for severe findings on the basis of sparse prior data, according to Peter Chin-Hong, MD, a professor of medicine and an infectious diseases physician at the University of California, San Francisco.

“We were on heightened alert that kids may do poorly,” said Dr. Chin-Hong, who was not involved in the study but who cared for monkeypox patients during the outbreak. “I think this study is reassuring.

“The other silver lining about it is that most of the kids got infected in the household setting from ways that you would expect them to get [infected],” Dr. Chin-Hong said in an interview.

However, Black and Hispanic children were more likely to contract the disease, underscoring troubling inequities.

“Early on, individuals of color were much less likely to be able to successfully access vaccination,” said first author Ian Hennessee, PhD, MPH, an epidemic intelligence service officer with the CDC and a member of the Special Case Investigation Unit of the Multinational Monkeypox Response Team at the CDC. “We think those kinds of structural inequities really trickled down towards the children and adolescents that have been affected by this outbreak.”

The study was published  in Morbidity and Mortality Weekly Report.
 

A nationwide look at the data

The researchers discussed 83 children and adolescents with monkeypox who came to the CDC’s attention between May 17 and Sept. 24, 2022.

The 83 cases represent 0.3% of the 25,038 reported monkeypox cases in the United States over that period. Of the 28 children aged 12 years or younger, 18 (64%) were boys. Sixteen children were younger than 4 years.

Exposure data were available for 20 (71%) of those aged 0-12. In that group, 19 were exposed at home; 17 cases were due to routine skin-to-skin contact with a household caregiver; and one case was suspected to be caused by fomites (such as a shared towel). Exposure information was unavailable for the remaining case.

Most of the children experienced lesions on the trunk. No lesions were anogenital. Two patients in the youngest age group were hospitalized because of widespread rash that involved the eyelids, and a patient in the 5- to 12-year-old group was hospitalized because of periorbital cellulitis and conjunctivitis.

Among those aged 13-17, there were 55 cases. Of these patients, 89% were boys. Exposure data were available for 35 (64%). In 32 of these patients, the infection occurred from presumed sexual contact. Twenty-three of those adolescents reported male-to-male sexual contact. No case was found to be connected with sexual abuse.

Lesions in the adolescents were mostly truncal or anogenital. Six in this group were hospitalized, and all of them recovered. One adolescent was found to be HIV positive.

Black and Hispanic children accounted for 47% and 35% of all cases, respectively.

Eleven percent of all the children and adolescents were hospitalized, and none received intensive care.

Treatments, when given, included the antiviral drug tecovirimat, intravenous vaccinia immune globulin, and topical trifluridine. There were no deaths.

Ten symptomatic patients attended school or daycare. Among these patients, no secondary transmissions were found to have occurred. Some contacts were offered the JYNNEOS monkeypox vaccine as postexposure prophylaxis.

Limitations of the study included potentially overlooked cases. Data were collected through routine surveillance, children frequently experience rashes, and access to testing has been a challenge, Dr. Hennessee explained.

In addition, data on exposure characteristics were missing for some children.
 

Inequities and the risks of being judged

The outbreak in the United States has eased in recent months. However, though uncommon in children, monkeypox has affected some racial groups disproportionately.

“Especially in the later course of the outbreak, the majority of cases were among Black and Hispanic individuals,” said co-author Rachel E. Harold, MD, an infectious diseases specialist and supervisory medical officer with the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STDs, and TB Administration.

“Unfortunately, the pediatric cases do reflect the outbreak overall,” she told this news organization.

Dr. Harold noted there have been efforts in D.C. and other jurisdictions, as well as by the White House monkeypox response team, to reach populations at greatest risk and that they were “really trying to make vaccine available to people of color.”

Vaccination clinics often popped up in unexpected locations at short notice, and that made it hard for some people to get to them, Dr. Chin-Hong pointed out.

Another factor was “the public aspect of accessing diagnostics and vaccines and the way that that’s linked to potential judgment or sexual risk,” he added.

“Not everybody’s out,” Dr. Chin-Hong said, referring to members of the LGBTQ community. “In many communities of color, going to get a test or going to get a vaccine essentially means that you’re out.”

For clinicians who suspect monkeypox in a child, Dr. Harold suggests keeping a broad differential diagnosis, looking for an epidemiologic link, and contacting the CDC for assistance. Infected children should be encouraged to avoid touching their own eyes or mucous membranes, she added.

In addition, she said, tecovirimat is a reasonable treatment and is well tolerated by pediatric monkeypox patients with eczema, an underlying condition that could lead to severe disease.

For infected caregivers, Dr. Hennessee said, measures to prevent infecting children at home include isolation, contact precautions, and in some cases, postexposure prophylaxis via vaccination.

For sexually active adolescents, he advised that clinicians offer vaccination, education on sexual health, and testing for HIV and other sexually transmitted infections.

“It’s important to remember that adolescents may be sexually active, and clinicians should do a thorough and nonjudgmental sexual history,” Dr. Harold added. “That is always true, but especially if there is concern for [monkeypox].”

Dr. Hennessee, Dr. Chin-Hong, and Dr. Harold have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Monkeypox, though often mild, may be severe and even fatal in immunocompromised individuals, particularly those with untreated AIDS, according to a Centers for Disease Control and Prevention study in Morbidity and Mortality Weekly Report.

The study described a group of patients recently treated for severe monkeypox. The majority were Black, HIV positive, and not receiving treatment. Many were also facing homelessness.

The authors urged HIV testing for all sexually active individuals with suspected monkeypox. Early or prolonged monkeypox treatment may be necessary, they concluded.

Coauthor John T. Brooks, MD, called the study “a real call to action.”

“If we want to reduce cases of severe monkeypox, we need to reduce the number of persons with HIV who are undiagnosed and not treated,” said Dr. Brooks, a medical epidemiologist who is chief medical officer of CDC›s multinational monkeypox response. Dr. Brooks also leads the epidemiology research team in CDC’s division of HIV/AIDS prevention.

The article reflects long-existing health disparities, noted Richard Silvera, MD, MPH, CPH, who is associate program director of the infectious diseases fellowship and assistant professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York. He was not involved with the study.

“These patients really have not been served by the health care system,” Dr. Silvera said. “Monkeypox is just really taking advantage of that.”
 

How severe monkeypox can manifest

The authors reported on 57 adults hospitalized with severe monkeypox between Aug. 10 and Sept. 10, 2022, for whose care the providers sought CDC consultation.

The vast majority (95%) were men, their median age was 34 years, and 68% were Black. Nearly one in four were homeless (23%).

Overall, 47 (82%) were HIV positive, of whom just 4 had been receiving antiretroviral therapy (ART). Of 43 for whom CD4 counts were known, 71% had fewer than 50 CD4 cells/mm3.

Clinical signs included severe skin lesions in all patients and severe mucosal lesions in 68%. Other affected organ systems included lungs (21%), eyes (21%), and central nervous system (7%).

Treatments included oral or intravenous tecovirimat (93% and 65%, respectively), vaccinia immune globulin intravenous (VIGIV, 51%), and cidofovir (23%).

Nearly 1 in 3 patients (30%) received care in an ICU; 12 died (21%). Monkeypox was considered the cause or a contributing factor in five of the deaths and not a factor in one death; the remaining six deaths are under investigation.
 

Case studies

The report included details of three representative cases of the CDC consultations.

One was a Hispanic man in his 20s with a fever of 102.8° F, a rash including eschars, oral lesions, neck mass, and cervical lymphadenopathy. He had tested positive for monkeypox as an outpatient and upon admission was found to be HIV positive, with a CD4 count of 79 cells/mm³. He experienced a severe and ultimately fatal clinical course that included intubation, refractory hypotension, seizures, renal failure, and cardiac arrest. An autopsy revealed diffuse organ necrosis plus orthopoxvirus and cytomegalovirus.

The second was a Black man in his 30s with untreated AIDS and diffuse rash. He was tested and treated for gonorrhea, chlamydia, and syphilis before phimosis and urinary retention led to admission and a monkeypox diagnosis 4 weeks after his rash began. He was discharged with oral tecovirimat, but his skin lesions developed necrosis and he was readmitted twice, each time with new lesions. His clinical course included methicillin-resistant Staphylococcus aureus bacteremia, atrial fibrillation, eye and ear involvement, a suprapubic catheter, and progressive necrosis of his lesions. As of the CDC report, he was receiving ART and intravenous tecovirimat.

The third patient, a White man in his 40s with untreated AIDS, presented with diffuse rash. He was promptly diagnosed with monkeypox and admitted for pain control. He was discharged with oral tecovirimat and ART, but homelessness and food insecurity jeopardized the absorption of his tecovirimat (which depends on a full fatty meal), and the lesions worsened. Despite readmission and aggressive medical treatment, the patient required finger debridement and a toe amputation. After discharge, he was again readmitted for lesions and pain and, at report publication, remained hospitalized, taking oral tecovirimat and ART.

The patients in the study may not be typical of severe monkeypox cases, wrote the authors reported. Deaths after the study period were not counted.
 

Fewer cases, some severe

As of Nov. 7, the CDC has confirmed 28,709 monkeypox cases. These have trended downward since August. Most people with recent diagnoses are men who are gay, bisexual, same gender loving, or who have sex with men, and most are Black, according to Brooks.

Dr. Brooks urges clinicians to report suspected monkeypox cases – especially severe ones – to their health departments.

“We don’t have a good bead on exactly how many severe cases there are in the States because of complexities in our surveillance systems,” Dr. Brooks said.

For patients with suspected or confirmed monkeypox, Brooks recommends testing for sexually transmitted infections, including HIV if status is unknown. Patients with HIV should receive prompt ART. For those at risk for severe disease, the authors recommend early treatment for suspected monkeypox, even before results are back. Some patients may benefit from tecovirimat courses lasting beyond 14 days, plus additional antivirals (cidofovir or brincidofovir) and/or VIGIV.

“With severe cases, clinicians may want to consider the value of more than one drug to attack the virus at different stages of its replication cycle,” Dr. Brooks said.
 

Inequities matter

The authors called on providers to engage communities burdened by HIV and to ensure access to not only monkeypox vaccination, diagnosis, and treatment but also sustained HIV care.

Dr. Silvera added that providers need to tailor care plans to patients’ social determinants of health. For example, he explained, inpatient care for monkeypox could be appropriate for some patients facing homelessness and food insecurity – even if they are able to take tecovirimat orally.

He recommends tapping others’ expertise: “Our social work colleagues are well versed in this.”

“I don’t think these clinicians failed these patients. ... I think everyone made all the right choices medically,” Dr. Silvera added. “I think that the system failed these patients – and we as clinicians are part of those systems. So we also have the power to change those systems. And I think we just need to start opening our eyes to that and [start] to work together towards that goal to take better care of our patients.”

Dr. Brooks reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Monkeypox, though often mild, may be severe and even fatal in immunocompromised individuals, particularly those with untreated AIDS, according to a Centers for Disease Control and Prevention study in Morbidity and Mortality Weekly Report.

The study described a group of patients recently treated for severe monkeypox. The majority were Black, HIV positive, and not receiving treatment. Many were also facing homelessness.

The authors urged HIV testing for all sexually active individuals with suspected monkeypox. Early or prolonged monkeypox treatment may be necessary, they concluded.

Coauthor John T. Brooks, MD, called the study “a real call to action.”

“If we want to reduce cases of severe monkeypox, we need to reduce the number of persons with HIV who are undiagnosed and not treated,” said Dr. Brooks, a medical epidemiologist who is chief medical officer of CDC›s multinational monkeypox response. Dr. Brooks also leads the epidemiology research team in CDC’s division of HIV/AIDS prevention.

The article reflects long-existing health disparities, noted Richard Silvera, MD, MPH, CPH, who is associate program director of the infectious diseases fellowship and assistant professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York. He was not involved with the study.

“These patients really have not been served by the health care system,” Dr. Silvera said. “Monkeypox is just really taking advantage of that.”
 

How severe monkeypox can manifest

The authors reported on 57 adults hospitalized with severe monkeypox between Aug. 10 and Sept. 10, 2022, for whose care the providers sought CDC consultation.

The vast majority (95%) were men, their median age was 34 years, and 68% were Black. Nearly one in four were homeless (23%).

Overall, 47 (82%) were HIV positive, of whom just 4 had been receiving antiretroviral therapy (ART). Of 43 for whom CD4 counts were known, 71% had fewer than 50 CD4 cells/mm3.

Clinical signs included severe skin lesions in all patients and severe mucosal lesions in 68%. Other affected organ systems included lungs (21%), eyes (21%), and central nervous system (7%).

Treatments included oral or intravenous tecovirimat (93% and 65%, respectively), vaccinia immune globulin intravenous (VIGIV, 51%), and cidofovir (23%).

Nearly 1 in 3 patients (30%) received care in an ICU; 12 died (21%). Monkeypox was considered the cause or a contributing factor in five of the deaths and not a factor in one death; the remaining six deaths are under investigation.
 

Case studies

The report included details of three representative cases of the CDC consultations.

One was a Hispanic man in his 20s with a fever of 102.8° F, a rash including eschars, oral lesions, neck mass, and cervical lymphadenopathy. He had tested positive for monkeypox as an outpatient and upon admission was found to be HIV positive, with a CD4 count of 79 cells/mm³. He experienced a severe and ultimately fatal clinical course that included intubation, refractory hypotension, seizures, renal failure, and cardiac arrest. An autopsy revealed diffuse organ necrosis plus orthopoxvirus and cytomegalovirus.

The second was a Black man in his 30s with untreated AIDS and diffuse rash. He was tested and treated for gonorrhea, chlamydia, and syphilis before phimosis and urinary retention led to admission and a monkeypox diagnosis 4 weeks after his rash began. He was discharged with oral tecovirimat, but his skin lesions developed necrosis and he was readmitted twice, each time with new lesions. His clinical course included methicillin-resistant Staphylococcus aureus bacteremia, atrial fibrillation, eye and ear involvement, a suprapubic catheter, and progressive necrosis of his lesions. As of the CDC report, he was receiving ART and intravenous tecovirimat.

The third patient, a White man in his 40s with untreated AIDS, presented with diffuse rash. He was promptly diagnosed with monkeypox and admitted for pain control. He was discharged with oral tecovirimat and ART, but homelessness and food insecurity jeopardized the absorption of his tecovirimat (which depends on a full fatty meal), and the lesions worsened. Despite readmission and aggressive medical treatment, the patient required finger debridement and a toe amputation. After discharge, he was again readmitted for lesions and pain and, at report publication, remained hospitalized, taking oral tecovirimat and ART.

The patients in the study may not be typical of severe monkeypox cases, wrote the authors reported. Deaths after the study period were not counted.
 

Fewer cases, some severe

As of Nov. 7, the CDC has confirmed 28,709 monkeypox cases. These have trended downward since August. Most people with recent diagnoses are men who are gay, bisexual, same gender loving, or who have sex with men, and most are Black, according to Brooks.

Dr. Brooks urges clinicians to report suspected monkeypox cases – especially severe ones – to their health departments.

“We don’t have a good bead on exactly how many severe cases there are in the States because of complexities in our surveillance systems,” Dr. Brooks said.

For patients with suspected or confirmed monkeypox, Brooks recommends testing for sexually transmitted infections, including HIV if status is unknown. Patients with HIV should receive prompt ART. For those at risk for severe disease, the authors recommend early treatment for suspected monkeypox, even before results are back. Some patients may benefit from tecovirimat courses lasting beyond 14 days, plus additional antivirals (cidofovir or brincidofovir) and/or VIGIV.

“With severe cases, clinicians may want to consider the value of more than one drug to attack the virus at different stages of its replication cycle,” Dr. Brooks said.
 

Inequities matter

The authors called on providers to engage communities burdened by HIV and to ensure access to not only monkeypox vaccination, diagnosis, and treatment but also sustained HIV care.

Dr. Silvera added that providers need to tailor care plans to patients’ social determinants of health. For example, he explained, inpatient care for monkeypox could be appropriate for some patients facing homelessness and food insecurity – even if they are able to take tecovirimat orally.

He recommends tapping others’ expertise: “Our social work colleagues are well versed in this.”

“I don’t think these clinicians failed these patients. ... I think everyone made all the right choices medically,” Dr. Silvera added. “I think that the system failed these patients – and we as clinicians are part of those systems. So we also have the power to change those systems. And I think we just need to start opening our eyes to that and [start] to work together towards that goal to take better care of our patients.”

Dr. Brooks reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Monkeypox, though often mild, may be severe and even fatal in immunocompromised individuals, particularly those with untreated AIDS, according to a Centers for Disease Control and Prevention study in Morbidity and Mortality Weekly Report.

The study described a group of patients recently treated for severe monkeypox. The majority were Black, HIV positive, and not receiving treatment. Many were also facing homelessness.

The authors urged HIV testing for all sexually active individuals with suspected monkeypox. Early or prolonged monkeypox treatment may be necessary, they concluded.

Coauthor John T. Brooks, MD, called the study “a real call to action.”

“If we want to reduce cases of severe monkeypox, we need to reduce the number of persons with HIV who are undiagnosed and not treated,” said Dr. Brooks, a medical epidemiologist who is chief medical officer of CDC›s multinational monkeypox response. Dr. Brooks also leads the epidemiology research team in CDC’s division of HIV/AIDS prevention.

The article reflects long-existing health disparities, noted Richard Silvera, MD, MPH, CPH, who is associate program director of the infectious diseases fellowship and assistant professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York. He was not involved with the study.

“These patients really have not been served by the health care system,” Dr. Silvera said. “Monkeypox is just really taking advantage of that.”
 

How severe monkeypox can manifest

The authors reported on 57 adults hospitalized with severe monkeypox between Aug. 10 and Sept. 10, 2022, for whose care the providers sought CDC consultation.

The vast majority (95%) were men, their median age was 34 years, and 68% were Black. Nearly one in four were homeless (23%).

Overall, 47 (82%) were HIV positive, of whom just 4 had been receiving antiretroviral therapy (ART). Of 43 for whom CD4 counts were known, 71% had fewer than 50 CD4 cells/mm3.

Clinical signs included severe skin lesions in all patients and severe mucosal lesions in 68%. Other affected organ systems included lungs (21%), eyes (21%), and central nervous system (7%).

Treatments included oral or intravenous tecovirimat (93% and 65%, respectively), vaccinia immune globulin intravenous (VIGIV, 51%), and cidofovir (23%).

Nearly 1 in 3 patients (30%) received care in an ICU; 12 died (21%). Monkeypox was considered the cause or a contributing factor in five of the deaths and not a factor in one death; the remaining six deaths are under investigation.
 

Case studies

The report included details of three representative cases of the CDC consultations.

One was a Hispanic man in his 20s with a fever of 102.8° F, a rash including eschars, oral lesions, neck mass, and cervical lymphadenopathy. He had tested positive for monkeypox as an outpatient and upon admission was found to be HIV positive, with a CD4 count of 79 cells/mm³. He experienced a severe and ultimately fatal clinical course that included intubation, refractory hypotension, seizures, renal failure, and cardiac arrest. An autopsy revealed diffuse organ necrosis plus orthopoxvirus and cytomegalovirus.

The second was a Black man in his 30s with untreated AIDS and diffuse rash. He was tested and treated for gonorrhea, chlamydia, and syphilis before phimosis and urinary retention led to admission and a monkeypox diagnosis 4 weeks after his rash began. He was discharged with oral tecovirimat, but his skin lesions developed necrosis and he was readmitted twice, each time with new lesions. His clinical course included methicillin-resistant Staphylococcus aureus bacteremia, atrial fibrillation, eye and ear involvement, a suprapubic catheter, and progressive necrosis of his lesions. As of the CDC report, he was receiving ART and intravenous tecovirimat.

The third patient, a White man in his 40s with untreated AIDS, presented with diffuse rash. He was promptly diagnosed with monkeypox and admitted for pain control. He was discharged with oral tecovirimat and ART, but homelessness and food insecurity jeopardized the absorption of his tecovirimat (which depends on a full fatty meal), and the lesions worsened. Despite readmission and aggressive medical treatment, the patient required finger debridement and a toe amputation. After discharge, he was again readmitted for lesions and pain and, at report publication, remained hospitalized, taking oral tecovirimat and ART.

The patients in the study may not be typical of severe monkeypox cases, wrote the authors reported. Deaths after the study period were not counted.
 

Fewer cases, some severe

As of Nov. 7, the CDC has confirmed 28,709 monkeypox cases. These have trended downward since August. Most people with recent diagnoses are men who are gay, bisexual, same gender loving, or who have sex with men, and most are Black, according to Brooks.

Dr. Brooks urges clinicians to report suspected monkeypox cases – especially severe ones – to their health departments.

“We don’t have a good bead on exactly how many severe cases there are in the States because of complexities in our surveillance systems,” Dr. Brooks said.

For patients with suspected or confirmed monkeypox, Brooks recommends testing for sexually transmitted infections, including HIV if status is unknown. Patients with HIV should receive prompt ART. For those at risk for severe disease, the authors recommend early treatment for suspected monkeypox, even before results are back. Some patients may benefit from tecovirimat courses lasting beyond 14 days, plus additional antivirals (cidofovir or brincidofovir) and/or VIGIV.

“With severe cases, clinicians may want to consider the value of more than one drug to attack the virus at different stages of its replication cycle,” Dr. Brooks said.
 

Inequities matter

The authors called on providers to engage communities burdened by HIV and to ensure access to not only monkeypox vaccination, diagnosis, and treatment but also sustained HIV care.

Dr. Silvera added that providers need to tailor care plans to patients’ social determinants of health. For example, he explained, inpatient care for monkeypox could be appropriate for some patients facing homelessness and food insecurity – even if they are able to take tecovirimat orally.

He recommends tapping others’ expertise: “Our social work colleagues are well versed in this.”

“I don’t think these clinicians failed these patients. ... I think everyone made all the right choices medically,” Dr. Silvera added. “I think that the system failed these patients – and we as clinicians are part of those systems. So we also have the power to change those systems. And I think we just need to start opening our eyes to that and [start] to work together towards that goal to take better care of our patients.”

Dr. Brooks reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

BUENOS AIRES – Emerging invasive fungal infections represent a new diagnostic and therapeutic challenge. To address their growing clinical impact on immunocompromised patients requires better local epidemiologic records, said a specialist at the XXII Congress of the Argentine Society of Infectology.
 

“To know that these fungal infections exist, we need epidemiologists, doctors, and microbiologists to join in constant and ongoing multidisciplinary work to generate the necessary databases and to know the pathologies that we have. I believe that in this respect we are falling short,” said Javier Afeltra, PhD, a mycologist at the Ramos Mejía Hospital in Buenos Aires, professor of microbiology at the School of Medicine of the University of Buenos Aires, and coordinator of the commission of immunocompromised patients of the Argentine Society of Infectious Diseases.

“There is some change in mentality that encourages professionals to report the cases they detect – for example, in scientific meetings,” Dr. Afeltra told this news orgnization. “But the problem is that there is no unified registry.

“That’s what we lack: a place to record all those isolated cases. Records where clinical and microbiological data are together within a click. Perhaps the microbiologists report their findings to the Malbrán Institute, an Argentine reference center for infectious disease research, but we do not know what the patients had. And we doctors may get together to make records of what happens clinically with the patient, but the germ data are elsewhere. We need a common registry,” he stressed.

“The main importance of a registry of this type is that it would allow a diagnostic and therapeutic decision to be made that is appropriate to the epidemiological profile of the country and the region, not looking at what they do in the North. Most likely, the best antifungal treatment for our country differs from what is indicated in the guidelines written elsewhere,” said Dr. Afeltra.

Dr. Afeltra pointed out that in the United States, when an oncohematology patient does not respond to antimicrobial treatment, the first thing that doctors think is that the patient has aspergillosis or mucormycosis, in which the fungal infection is caused by filamentous fungi.

But an analysis of data from the REMINI registry – the only prospective, observational, multicenter surveillance registry for invasive mycoses in immunocompromised patients (excluding HIV infection) in Argentina, which has been in existence since 2010 – tells a different story. The most prevalent fungal infections turned out to be those caused by Aspergillus species, followed by Fusarium species. Together, they account for more than half of cases. Mucoral infections (mucormycosis) account for less than 6%. And the initial treatments for these diseases could be different.

Changes in the local epidemiology can occur because the behavior of phytopathogenic fungi found in the environment can be modified. For example, cases of chronic mucormycosis can be detected in China but are virtually nonexistent on this side of the Greenwich meridian, Dr. Afeltra said.

“Nature is not the same in geographical areas, and the fungi … we breathe are completely different, so patients have different infections and require different diagnostic and treatment approaches,” he stressed.

Dr. Afeltra mentioned different fungi that are emerging locally and globally, including yeasts, septate, dimorphic, and pigmented hyaline fungi, that have a variable response to antifungal drugs and are associated with high mortality, “which has a lot to do with a later diagnosis,” he said, noting that reports have increased worldwide. A barrier to sharing this information more widely with the professional community, in addition to the lack of records, is the difficulty in publishing cases or series of cases in indexed journals.

Another challenge in characterizing the phenomenon is in regard to taxonomic reclassifications of fungi. Such reclassifications can mean that “perhaps we are speaking of the same pathogen in similar situations, believing that we are referring to different pathogens,” said Dr. Afeltra.
 

Clinical pearls related to emerging fungal pathogens

Candida auris. This organism has emerged simultaneously on several continents. It has pathogenicity factors typical of the genus, such as biofilm formation and production of phospholipases and proteinases, although it has greater thermal tolerance. In hospitals, it colonizes for weeks and months. In Argentina, it is resistant to multiple antifungal agents. Sensitivity is variable in different geographical regions. Most strains are resistant to fluconazole, and there is variable resistance to the other triazoles [which are not normally used to treat candidemia]. In the United States, in vitro resistance to amphotericin B is up to 30%, and resistance to echinocandins is up to 5%. New drugs such as rezafungin and ibrexafungerp are being studied. Infection control is similar to that used to control Clostridium difficile.

Fusarium. This genus affects immunocompromised patients, including transplant recipients of solid organs and hematopoietic progenitor cells and patients with neutropenia. The genus has various species, included within complexes, such as F. solani SC, F. oxysporum SC, and F. fujikuroi SC, with clinical manifestations similar to those of aspergillosis. In addition to the pulmonary and disseminated forms, there may be skin involvement attributable to dissemination from a respiratory focus or by contiguity from a focus of onychomycosis. In general, mortality is high, and responses to antifungal agents are variable. Some species are more sensitive to voriconazole or posaconazole, and others less so. All show in vitro resistance to itraconazole. In Argentina, voriconazole is usually used as initial treatment, and in special cases, liposomal amphotericin B or combinations. Fosmanogepix is being evaluated for the future.

Azole-resistant aspergillosis. This infection has shown resistance to itraconazole and third-generation azole drugs. In immunocompromised patients, mortlaity is high. Early detection is key. It is sensitive to amphotericin B and echinocandins. It is generally treated with liposomal amphotericin B. Olorofim and fosmanogepix are being studied.

Pulmonary aspergillosis associated with COVID-19. This infection is associated with high mortality among intubated patients. Signs and symptoms include fever, pleural effusion, hemoptysis, and chest pain, with infiltrates or cavitations on imaging. Determining the diagnosis is difficult. “We couldn’t perform lung biopsies, and it was difficult for us to get patients out of intensive care units for CT scans. We treated the proven cases. We treated the probable cases, and those that had a very low certainty of disease were also treated. We came across this emergency and tried to do the best we could,” said Dr. Afeltra. A digital readout lateral flow trial (Sona Aspergillus Galactomannan LFA) for the quantification of galactomannan, a cell wall component of the Aspergillus genus, proved to be a useful tool for screening and diagnosing patients with probable pulmonary aspergillosis associated with COVID-19. The incidence of invasive mycosis was around 10% among 185 seriously ill COVID-19 patients, according to an Argentine multicenter prospective study in which Dr. Afeltra participated.

Scedosporium and Lomentospora. These genera are rarer septate hyaline fungi. Scedosporium is a complex of species. One species, S. apiospermum, can colonize pediatric patients with cystic fibrosis. Lomentospora prolificans is a multiresistant fungus. It produces pulmonary compromise or disseminated infection. The response to antifungal agents is variable, with a high minimum inhibitory concentration for amphotericin B and isavuconazole. Patients are usually treated with voriconazole alone or in combination with terbinafine or micafungin. Olorofim is emerging as a promising treatment.

Dr. Afeltra has received fees from Biotoscana, Gador, Pfizer, Merck, and Sandoz.

This article was translated from the Medscape Spanish edition, a version appeared on Medscape.com.

BUENOS AIRES – Emerging invasive fungal infections represent a new diagnostic and therapeutic challenge. To address their growing clinical impact on immunocompromised patients requires better local epidemiologic records, said a specialist at the XXII Congress of the Argentine Society of Infectology.
 

“To know that these fungal infections exist, we need epidemiologists, doctors, and microbiologists to join in constant and ongoing multidisciplinary work to generate the necessary databases and to know the pathologies that we have. I believe that in this respect we are falling short,” said Javier Afeltra, PhD, a mycologist at the Ramos Mejía Hospital in Buenos Aires, professor of microbiology at the School of Medicine of the University of Buenos Aires, and coordinator of the commission of immunocompromised patients of the Argentine Society of Infectious Diseases.

“There is some change in mentality that encourages professionals to report the cases they detect – for example, in scientific meetings,” Dr. Afeltra told this news orgnization. “But the problem is that there is no unified registry.

“That’s what we lack: a place to record all those isolated cases. Records where clinical and microbiological data are together within a click. Perhaps the microbiologists report their findings to the Malbrán Institute, an Argentine reference center for infectious disease research, but we do not know what the patients had. And we doctors may get together to make records of what happens clinically with the patient, but the germ data are elsewhere. We need a common registry,” he stressed.

“The main importance of a registry of this type is that it would allow a diagnostic and therapeutic decision to be made that is appropriate to the epidemiological profile of the country and the region, not looking at what they do in the North. Most likely, the best antifungal treatment for our country differs from what is indicated in the guidelines written elsewhere,” said Dr. Afeltra.

Dr. Afeltra pointed out that in the United States, when an oncohematology patient does not respond to antimicrobial treatment, the first thing that doctors think is that the patient has aspergillosis or mucormycosis, in which the fungal infection is caused by filamentous fungi.

But an analysis of data from the REMINI registry – the only prospective, observational, multicenter surveillance registry for invasive mycoses in immunocompromised patients (excluding HIV infection) in Argentina, which has been in existence since 2010 – tells a different story. The most prevalent fungal infections turned out to be those caused by Aspergillus species, followed by Fusarium species. Together, they account for more than half of cases. Mucoral infections (mucormycosis) account for less than 6%. And the initial treatments for these diseases could be different.

Changes in the local epidemiology can occur because the behavior of phytopathogenic fungi found in the environment can be modified. For example, cases of chronic mucormycosis can be detected in China but are virtually nonexistent on this side of the Greenwich meridian, Dr. Afeltra said.

“Nature is not the same in geographical areas, and the fungi … we breathe are completely different, so patients have different infections and require different diagnostic and treatment approaches,” he stressed.

Dr. Afeltra mentioned different fungi that are emerging locally and globally, including yeasts, septate, dimorphic, and pigmented hyaline fungi, that have a variable response to antifungal drugs and are associated with high mortality, “which has a lot to do with a later diagnosis,” he said, noting that reports have increased worldwide. A barrier to sharing this information more widely with the professional community, in addition to the lack of records, is the difficulty in publishing cases or series of cases in indexed journals.

Another challenge in characterizing the phenomenon is in regard to taxonomic reclassifications of fungi. Such reclassifications can mean that “perhaps we are speaking of the same pathogen in similar situations, believing that we are referring to different pathogens,” said Dr. Afeltra.
 

Clinical pearls related to emerging fungal pathogens

Candida auris. This organism has emerged simultaneously on several continents. It has pathogenicity factors typical of the genus, such as biofilm formation and production of phospholipases and proteinases, although it has greater thermal tolerance. In hospitals, it colonizes for weeks and months. In Argentina, it is resistant to multiple antifungal agents. Sensitivity is variable in different geographical regions. Most strains are resistant to fluconazole, and there is variable resistance to the other triazoles [which are not normally used to treat candidemia]. In the United States, in vitro resistance to amphotericin B is up to 30%, and resistance to echinocandins is up to 5%. New drugs such as rezafungin and ibrexafungerp are being studied. Infection control is similar to that used to control Clostridium difficile.

Fusarium. This genus affects immunocompromised patients, including transplant recipients of solid organs and hematopoietic progenitor cells and patients with neutropenia. The genus has various species, included within complexes, such as F. solani SC, F. oxysporum SC, and F. fujikuroi SC, with clinical manifestations similar to those of aspergillosis. In addition to the pulmonary and disseminated forms, there may be skin involvement attributable to dissemination from a respiratory focus or by contiguity from a focus of onychomycosis. In general, mortality is high, and responses to antifungal agents are variable. Some species are more sensitive to voriconazole or posaconazole, and others less so. All show in vitro resistance to itraconazole. In Argentina, voriconazole is usually used as initial treatment, and in special cases, liposomal amphotericin B or combinations. Fosmanogepix is being evaluated for the future.

Azole-resistant aspergillosis. This infection has shown resistance to itraconazole and third-generation azole drugs. In immunocompromised patients, mortlaity is high. Early detection is key. It is sensitive to amphotericin B and echinocandins. It is generally treated with liposomal amphotericin B. Olorofim and fosmanogepix are being studied.

Pulmonary aspergillosis associated with COVID-19. This infection is associated with high mortality among intubated patients. Signs and symptoms include fever, pleural effusion, hemoptysis, and chest pain, with infiltrates or cavitations on imaging. Determining the diagnosis is difficult. “We couldn’t perform lung biopsies, and it was difficult for us to get patients out of intensive care units for CT scans. We treated the proven cases. We treated the probable cases, and those that had a very low certainty of disease were also treated. We came across this emergency and tried to do the best we could,” said Dr. Afeltra. A digital readout lateral flow trial (Sona Aspergillus Galactomannan LFA) for the quantification of galactomannan, a cell wall component of the Aspergillus genus, proved to be a useful tool for screening and diagnosing patients with probable pulmonary aspergillosis associated with COVID-19. The incidence of invasive mycosis was around 10% among 185 seriously ill COVID-19 patients, according to an Argentine multicenter prospective study in which Dr. Afeltra participated.

Scedosporium and Lomentospora. These genera are rarer septate hyaline fungi. Scedosporium is a complex of species. One species, S. apiospermum, can colonize pediatric patients with cystic fibrosis. Lomentospora prolificans is a multiresistant fungus. It produces pulmonary compromise or disseminated infection. The response to antifungal agents is variable, with a high minimum inhibitory concentration for amphotericin B and isavuconazole. Patients are usually treated with voriconazole alone or in combination with terbinafine or micafungin. Olorofim is emerging as a promising treatment.

Dr. Afeltra has received fees from Biotoscana, Gador, Pfizer, Merck, and Sandoz.

This article was translated from the Medscape Spanish edition, a version appeared on Medscape.com.

BUENOS AIRES – Emerging invasive fungal infections represent a new diagnostic and therapeutic challenge. To address their growing clinical impact on immunocompromised patients requires better local epidemiologic records, said a specialist at the XXII Congress of the Argentine Society of Infectology.
 

“To know that these fungal infections exist, we need epidemiologists, doctors, and microbiologists to join in constant and ongoing multidisciplinary work to generate the necessary databases and to know the pathologies that we have. I believe that in this respect we are falling short,” said Javier Afeltra, PhD, a mycologist at the Ramos Mejía Hospital in Buenos Aires, professor of microbiology at the School of Medicine of the University of Buenos Aires, and coordinator of the commission of immunocompromised patients of the Argentine Society of Infectious Diseases.

“There is some change in mentality that encourages professionals to report the cases they detect – for example, in scientific meetings,” Dr. Afeltra told this news orgnization. “But the problem is that there is no unified registry.

“That’s what we lack: a place to record all those isolated cases. Records where clinical and microbiological data are together within a click. Perhaps the microbiologists report their findings to the Malbrán Institute, an Argentine reference center for infectious disease research, but we do not know what the patients had. And we doctors may get together to make records of what happens clinically with the patient, but the germ data are elsewhere. We need a common registry,” he stressed.

“The main importance of a registry of this type is that it would allow a diagnostic and therapeutic decision to be made that is appropriate to the epidemiological profile of the country and the region, not looking at what they do in the North. Most likely, the best antifungal treatment for our country differs from what is indicated in the guidelines written elsewhere,” said Dr. Afeltra.

Dr. Afeltra pointed out that in the United States, when an oncohematology patient does not respond to antimicrobial treatment, the first thing that doctors think is that the patient has aspergillosis or mucormycosis, in which the fungal infection is caused by filamentous fungi.

But an analysis of data from the REMINI registry – the only prospective, observational, multicenter surveillance registry for invasive mycoses in immunocompromised patients (excluding HIV infection) in Argentina, which has been in existence since 2010 – tells a different story. The most prevalent fungal infections turned out to be those caused by Aspergillus species, followed by Fusarium species. Together, they account for more than half of cases. Mucoral infections (mucormycosis) account for less than 6%. And the initial treatments for these diseases could be different.

Changes in the local epidemiology can occur because the behavior of phytopathogenic fungi found in the environment can be modified. For example, cases of chronic mucormycosis can be detected in China but are virtually nonexistent on this side of the Greenwich meridian, Dr. Afeltra said.

“Nature is not the same in geographical areas, and the fungi … we breathe are completely different, so patients have different infections and require different diagnostic and treatment approaches,” he stressed.

Dr. Afeltra mentioned different fungi that are emerging locally and globally, including yeasts, septate, dimorphic, and pigmented hyaline fungi, that have a variable response to antifungal drugs and are associated with high mortality, “which has a lot to do with a later diagnosis,” he said, noting that reports have increased worldwide. A barrier to sharing this information more widely with the professional community, in addition to the lack of records, is the difficulty in publishing cases or series of cases in indexed journals.

Another challenge in characterizing the phenomenon is in regard to taxonomic reclassifications of fungi. Such reclassifications can mean that “perhaps we are speaking of the same pathogen in similar situations, believing that we are referring to different pathogens,” said Dr. Afeltra.
 

Clinical pearls related to emerging fungal pathogens

Candida auris. This organism has emerged simultaneously on several continents. It has pathogenicity factors typical of the genus, such as biofilm formation and production of phospholipases and proteinases, although it has greater thermal tolerance. In hospitals, it colonizes for weeks and months. In Argentina, it is resistant to multiple antifungal agents. Sensitivity is variable in different geographical regions. Most strains are resistant to fluconazole, and there is variable resistance to the other triazoles [which are not normally used to treat candidemia]. In the United States, in vitro resistance to amphotericin B is up to 30%, and resistance to echinocandins is up to 5%. New drugs such as rezafungin and ibrexafungerp are being studied. Infection control is similar to that used to control Clostridium difficile.

Fusarium. This genus affects immunocompromised patients, including transplant recipients of solid organs and hematopoietic progenitor cells and patients with neutropenia. The genus has various species, included within complexes, such as F. solani SC, F. oxysporum SC, and F. fujikuroi SC, with clinical manifestations similar to those of aspergillosis. In addition to the pulmonary and disseminated forms, there may be skin involvement attributable to dissemination from a respiratory focus or by contiguity from a focus of onychomycosis. In general, mortality is high, and responses to antifungal agents are variable. Some species are more sensitive to voriconazole or posaconazole, and others less so. All show in vitro resistance to itraconazole. In Argentina, voriconazole is usually used as initial treatment, and in special cases, liposomal amphotericin B or combinations. Fosmanogepix is being evaluated for the future.

Azole-resistant aspergillosis. This infection has shown resistance to itraconazole and third-generation azole drugs. In immunocompromised patients, mortlaity is high. Early detection is key. It is sensitive to amphotericin B and echinocandins. It is generally treated with liposomal amphotericin B. Olorofim and fosmanogepix are being studied.

Pulmonary aspergillosis associated with COVID-19. This infection is associated with high mortality among intubated patients. Signs and symptoms include fever, pleural effusion, hemoptysis, and chest pain, with infiltrates or cavitations on imaging. Determining the diagnosis is difficult. “We couldn’t perform lung biopsies, and it was difficult for us to get patients out of intensive care units for CT scans. We treated the proven cases. We treated the probable cases, and those that had a very low certainty of disease were also treated. We came across this emergency and tried to do the best we could,” said Dr. Afeltra. A digital readout lateral flow trial (Sona Aspergillus Galactomannan LFA) for the quantification of galactomannan, a cell wall component of the Aspergillus genus, proved to be a useful tool for screening and diagnosing patients with probable pulmonary aspergillosis associated with COVID-19. The incidence of invasive mycosis was around 10% among 185 seriously ill COVID-19 patients, according to an Argentine multicenter prospective study in which Dr. Afeltra participated.

Scedosporium and Lomentospora. These genera are rarer septate hyaline fungi. Scedosporium is a complex of species. One species, S. apiospermum, can colonize pediatric patients with cystic fibrosis. Lomentospora prolificans is a multiresistant fungus. It produces pulmonary compromise or disseminated infection. The response to antifungal agents is variable, with a high minimum inhibitory concentration for amphotericin B and isavuconazole. Patients are usually treated with voriconazole alone or in combination with terbinafine or micafungin. Olorofim is emerging as a promising treatment.

Dr. Afeltra has received fees from Biotoscana, Gador, Pfizer, Merck, and Sandoz.

This article was translated from the Medscape Spanish edition, a version appeared on Medscape.com.

Climate change has affected the spread of West Nile fever. This observation was confirmed in an Italian Ministry of Health note reporting 94 confirmed cases of infection. Of those cases, 55 were neuroinvasive, 19 were from blood donors, 19 were associated with fever, and in one case, the patient was symptomatic. Seven deaths have occurred since the start of the summer season, particularly in northern Italy.

Entomologists and veterinarians have confirmed the presence of West Nile virus (WNV) in a pool of 100 mosquitoes, 15 birds from targeted species, and 10 wild birds from passive surveillance. Four cases have been reported in horses in which clinical symptoms were attributable to a WNV infection. No cases of infection with Usutu virus (USUV) have been registered in humans. USUV is a virus in the same family as WNV. It was first identified in South Africa in the 1950s and is capable of causing encephalitis. The viral genome has been detected in a pool of 33 mosquitoes and four birds.

Currently, the regions where the circulation of WNV has been confirmed are Emilia-Romagna, Veneto, Piedmont, Lombardy, Sardinia, and Friuli Venezia Giulia. To date, USUV has been detected in Le Marche, Lombardy, Umbria, Emilia Romagna, Friuli Venezia Giulia, Lazio, and Veneto.

Current climate conditions favor the reproduction of the vector (mosquitoes of the Culex genus) and the subsequent viral circulation among wildlife, the natural reservoir of the virus, and mammals (including humans). The 2022 epidemic season is peculiar in comparison with seasons from the past 3 years. Viral circulation has started early, and a greater number of cases have been observed in the avifauna and in the mosquito pool, and there has been an increase in the number of cases in humans.

For these reasons, and considering the significance of the infection for public health, it is necessary to put all useful measures in place to limit the risk of further transmission among humans and animals.

As specified on the Italian National Institute for Health website, West Nile fever is caused by the homonymous virus of the Flaviviridae family, which was isolated for the first time in Uganda in 1937. The virus has spread to almost all continents.

The virus reservoirs are wild birds and mosquitoes (more frequently of the Culex genus). Mosquito bites are the main means of transmission to humans. Other means of transmission, although very rare, are organ transplants, blood transfusions, and transmission from mother to fetus. West Nile fever cannot be transmitted from person to person. The virus infects other mammals, especially horses, and in some cases, dogs and rabbits.
 

Incubation and symptoms

The incubation period from the time of being bitten by an infected mosquito ranges from 2 to 14 days but can be up to 21 days in immunocompromised patients.

Most infected people do not show any symptoms. In around 20% of symptomatic cases, patients present with mild symptoms: fever, headache, nausea, vomiting, enlarged lymph nodes, and skin rashes. These symptoms may only last a few hours, but in rare cases, they may last a few weeks. Symptoms vary significantly, depending on the patient’s age. In children, a mild fever is most common, whereas in young people, symptoms are characterized by a fairly high fever, redness of the eyes, headache, and muscle pains. In the elderly and in debilitated patients, symptoms can be more severe.

The most serious symptoms are seen in fewer than 1% of infected patients (1 in 150 people) and include a high fever, a severe headache, muscle weakness, disorientation, tremors, visual disturbances, listlessness, and seizures, leading to paralysis and coma. Some neurologic effects may be permanent. In the most severe cases (around 1 in 1,000), the virus can cause terminal encephalitis.
 

Diagnosis

Diagnosis is mostly made through laboratory testing for IgM antibodies on serum and, where indicated, cerebrospinal fluid (CSF). Antibodies can persist beyond the patient’s period of illness (up to 1 year). Therefore, a positive result may indicate a previous infection. Samples collected within 8 days of the onset of symptoms may appear negative; it is therefore advisable to repeat the laboratory test further down the line before excluding the disease. Alternatively, diagnosis may be obtained through polymerase chain reaction or viral culture testing on samples of serum or CSF.
 

Prevention

A vaccine for West Nile fever does not exist. Prevention consists, above all, of reducing exposure to mosquito bites.

It is advisable that people protect themselves against bites and avoid places where mosquitoes can reproduce easily. The following are recommended:

• Using repellents and wearing of trousers and long-sleeve tops when out in the open, especially at dawn and sunset.
• Using mosquito nets on windows.
• Frequently emptying vases or other containers (for example, buckets) that contain stagnant water.
• Frequently changing the water in animal drinking bowls.
• Keeping child paddling pools in a vertical position when not in use.
• Using authorized repellents and insecticides where the vector may reproduce, such as in stables. For horses, a vaccine is available for veterinary use, which can further reduce the reservoir of viral circulation.

It is important that physicians inform patients in at-risk areas of the presence of this virus, the possible symptoms, and the preventive measures to adopt.
 

Therapy and treatment

There is no specific therapy for West Nile fever. In most cases, symptoms appear after a few days, but they can last for a few weeks. For the most severe cases, hospital admission is necessary; occasionally, treatment in the intensive care unit is necessary.

This article was translated from Univadis Italy. A version appeared on Medscape.com.

Climate change has affected the spread of West Nile fever. This observation was confirmed in an Italian Ministry of Health note reporting 94 confirmed cases of infection. Of those cases, 55 were neuroinvasive, 19 were from blood donors, 19 were associated with fever, and in one case, the patient was symptomatic. Seven deaths have occurred since the start of the summer season, particularly in northern Italy.

Entomologists and veterinarians have confirmed the presence of West Nile virus (WNV) in a pool of 100 mosquitoes, 15 birds from targeted species, and 10 wild birds from passive surveillance. Four cases have been reported in horses in which clinical symptoms were attributable to a WNV infection. No cases of infection with Usutu virus (USUV) have been registered in humans. USUV is a virus in the same family as WNV. It was first identified in South Africa in the 1950s and is capable of causing encephalitis. The viral genome has been detected in a pool of 33 mosquitoes and four birds.

Currently, the regions where the circulation of WNV has been confirmed are Emilia-Romagna, Veneto, Piedmont, Lombardy, Sardinia, and Friuli Venezia Giulia. To date, USUV has been detected in Le Marche, Lombardy, Umbria, Emilia Romagna, Friuli Venezia Giulia, Lazio, and Veneto.

Current climate conditions favor the reproduction of the vector (mosquitoes of the Culex genus) and the subsequent viral circulation among wildlife, the natural reservoir of the virus, and mammals (including humans). The 2022 epidemic season is peculiar in comparison with seasons from the past 3 years. Viral circulation has started early, and a greater number of cases have been observed in the avifauna and in the mosquito pool, and there has been an increase in the number of cases in humans.

For these reasons, and considering the significance of the infection for public health, it is necessary to put all useful measures in place to limit the risk of further transmission among humans and animals.

As specified on the Italian National Institute for Health website, West Nile fever is caused by the homonymous virus of the Flaviviridae family, which was isolated for the first time in Uganda in 1937. The virus has spread to almost all continents.

The virus reservoirs are wild birds and mosquitoes (more frequently of the Culex genus). Mosquito bites are the main means of transmission to humans. Other means of transmission, although very rare, are organ transplants, blood transfusions, and transmission from mother to fetus. West Nile fever cannot be transmitted from person to person. The virus infects other mammals, especially horses, and in some cases, dogs and rabbits.
 

Incubation and symptoms

The incubation period from the time of being bitten by an infected mosquito ranges from 2 to 14 days but can be up to 21 days in immunocompromised patients.

Most infected people do not show any symptoms. In around 20% of symptomatic cases, patients present with mild symptoms: fever, headache, nausea, vomiting, enlarged lymph nodes, and skin rashes. These symptoms may only last a few hours, but in rare cases, they may last a few weeks. Symptoms vary significantly, depending on the patient’s age. In children, a mild fever is most common, whereas in young people, symptoms are characterized by a fairly high fever, redness of the eyes, headache, and muscle pains. In the elderly and in debilitated patients, symptoms can be more severe.

The most serious symptoms are seen in fewer than 1% of infected patients (1 in 150 people) and include a high fever, a severe headache, muscle weakness, disorientation, tremors, visual disturbances, listlessness, and seizures, leading to paralysis and coma. Some neurologic effects may be permanent. In the most severe cases (around 1 in 1,000), the virus can cause terminal encephalitis.
 

Diagnosis

Diagnosis is mostly made through laboratory testing for IgM antibodies on serum and, where indicated, cerebrospinal fluid (CSF). Antibodies can persist beyond the patient’s period of illness (up to 1 year). Therefore, a positive result may indicate a previous infection. Samples collected within 8 days of the onset of symptoms may appear negative; it is therefore advisable to repeat the laboratory test further down the line before excluding the disease. Alternatively, diagnosis may be obtained through polymerase chain reaction or viral culture testing on samples of serum or CSF.
 

Prevention

A vaccine for West Nile fever does not exist. Prevention consists, above all, of reducing exposure to mosquito bites.

It is advisable that people protect themselves against bites and avoid places where mosquitoes can reproduce easily. The following are recommended:

• Using repellents and wearing of trousers and long-sleeve tops when out in the open, especially at dawn and sunset.
• Using mosquito nets on windows.
• Frequently emptying vases or other containers (for example, buckets) that contain stagnant water.
• Frequently changing the water in animal drinking bowls.
• Keeping child paddling pools in a vertical position when not in use.
• Using authorized repellents and insecticides where the vector may reproduce, such as in stables. For horses, a vaccine is available for veterinary use, which can further reduce the reservoir of viral circulation.

It is important that physicians inform patients in at-risk areas of the presence of this virus, the possible symptoms, and the preventive measures to adopt.
 

Therapy and treatment

There is no specific therapy for West Nile fever. In most cases, symptoms appear after a few days, but they can last for a few weeks. For the most severe cases, hospital admission is necessary; occasionally, treatment in the intensive care unit is necessary.

This article was translated from Univadis Italy. A version appeared on Medscape.com.

Climate change has affected the spread of West Nile fever. This observation was confirmed in an Italian Ministry of Health note reporting 94 confirmed cases of infection. Of those cases, 55 were neuroinvasive, 19 were from blood donors, 19 were associated with fever, and in one case, the patient was symptomatic. Seven deaths have occurred since the start of the summer season, particularly in northern Italy.

Entomologists and veterinarians have confirmed the presence of West Nile virus (WNV) in a pool of 100 mosquitoes, 15 birds from targeted species, and 10 wild birds from passive surveillance. Four cases have been reported in horses in which clinical symptoms were attributable to a WNV infection. No cases of infection with Usutu virus (USUV) have been registered in humans. USUV is a virus in the same family as WNV. It was first identified in South Africa in the 1950s and is capable of causing encephalitis. The viral genome has been detected in a pool of 33 mosquitoes and four birds.

Currently, the regions where the circulation of WNV has been confirmed are Emilia-Romagna, Veneto, Piedmont, Lombardy, Sardinia, and Friuli Venezia Giulia. To date, USUV has been detected in Le Marche, Lombardy, Umbria, Emilia Romagna, Friuli Venezia Giulia, Lazio, and Veneto.

Current climate conditions favor the reproduction of the vector (mosquitoes of the Culex genus) and the subsequent viral circulation among wildlife, the natural reservoir of the virus, and mammals (including humans). The 2022 epidemic season is peculiar in comparison with seasons from the past 3 years. Viral circulation has started early, and a greater number of cases have been observed in the avifauna and in the mosquito pool, and there has been an increase in the number of cases in humans.

For these reasons, and considering the significance of the infection for public health, it is necessary to put all useful measures in place to limit the risk of further transmission among humans and animals.

As specified on the Italian National Institute for Health website, West Nile fever is caused by the homonymous virus of the Flaviviridae family, which was isolated for the first time in Uganda in 1937. The virus has spread to almost all continents.

The virus reservoirs are wild birds and mosquitoes (more frequently of the Culex genus). Mosquito bites are the main means of transmission to humans. Other means of transmission, although very rare, are organ transplants, blood transfusions, and transmission from mother to fetus. West Nile fever cannot be transmitted from person to person. The virus infects other mammals, especially horses, and in some cases, dogs and rabbits.
 

Incubation and symptoms

The incubation period from the time of being bitten by an infected mosquito ranges from 2 to 14 days but can be up to 21 days in immunocompromised patients.

Most infected people do not show any symptoms. In around 20% of symptomatic cases, patients present with mild symptoms: fever, headache, nausea, vomiting, enlarged lymph nodes, and skin rashes. These symptoms may only last a few hours, but in rare cases, they may last a few weeks. Symptoms vary significantly, depending on the patient’s age. In children, a mild fever is most common, whereas in young people, symptoms are characterized by a fairly high fever, redness of the eyes, headache, and muscle pains. In the elderly and in debilitated patients, symptoms can be more severe.

The most serious symptoms are seen in fewer than 1% of infected patients (1 in 150 people) and include a high fever, a severe headache, muscle weakness, disorientation, tremors, visual disturbances, listlessness, and seizures, leading to paralysis and coma. Some neurologic effects may be permanent. In the most severe cases (around 1 in 1,000), the virus can cause terminal encephalitis.
 

Diagnosis

Diagnosis is mostly made through laboratory testing for IgM antibodies on serum and, where indicated, cerebrospinal fluid (CSF). Antibodies can persist beyond the patient’s period of illness (up to 1 year). Therefore, a positive result may indicate a previous infection. Samples collected within 8 days of the onset of symptoms may appear negative; it is therefore advisable to repeat the laboratory test further down the line before excluding the disease. Alternatively, diagnosis may be obtained through polymerase chain reaction or viral culture testing on samples of serum or CSF.
 

Prevention

A vaccine for West Nile fever does not exist. Prevention consists, above all, of reducing exposure to mosquito bites.

It is advisable that people protect themselves against bites and avoid places where mosquitoes can reproduce easily. The following are recommended:

• Using repellents and wearing of trousers and long-sleeve tops when out in the open, especially at dawn and sunset.
• Using mosquito nets on windows.
• Frequently emptying vases or other containers (for example, buckets) that contain stagnant water.
• Frequently changing the water in animal drinking bowls.
• Keeping child paddling pools in a vertical position when not in use.
• Using authorized repellents and insecticides where the vector may reproduce, such as in stables. For horses, a vaccine is available for veterinary use, which can further reduce the reservoir of viral circulation.

It is important that physicians inform patients in at-risk areas of the presence of this virus, the possible symptoms, and the preventive measures to adopt.
 

Therapy and treatment

There is no specific therapy for West Nile fever. In most cases, symptoms appear after a few days, but they can last for a few weeks. For the most severe cases, hospital admission is necessary; occasionally, treatment in the intensive care unit is necessary.

This article was translated from Univadis Italy. A version appeared on Medscape.com.

Between 2018 and August 2022, Chinese researchers identified 35 people infected with a new animal virus in eastern China. These cases were reported in The New England Journal of Medicine. When asked by Nature about this emerging virus that has until now flown under the radar, scientists said that they were not overly concerned because the virus doesn’t seem to spread easily between people nor is it fatal.

Researchers think that the virus is carried by shrews. It might have infected people directly or through an intermediate animal.
 

First identified in Langya

The authors describe 35 cases of infection with a virus called Langya henipavirus (LayV) since 2018. It is closely related to two other henipaviruses known to infect people – Hendra virus and Nipah virus. The virus was named Langya after the town in Shandong province in China where the first patient identified with the disease was from, explained coauthor Linfa Wang, PhD, a virologist at Duke-NUS Medical School, Singapore.

Langya can cause respiratory symptoms such as fever, cough, and fatigue. Hendra virus and Nipah virus also cause respiratory infections and can be fatal, the article in Nature reports.
 

Hendra and Nipah

According to the World Health Organization, Nipah virus, which was discovered in 1999, is a new virus responsible for a zoonosis that causes the disease in animals and humans who have had contact with infected animals. Its name comes from the location where it was first identified in Malaysia. Patients may have asymptomatic infection or symptoms such as acute respiratory infection and severe encephalitis. The case fatality rate is between 40% and 75%.

Nipah virus is closely related to another recently discovered (1994) zoonotic virus called Hendra virus, which is named after the Australian city in which it first appeared. On that day in July 2016, 53 cases were identified involving 70 horses. These incidents remained confined to the northeastern coast of Australia.

Nipah virus and Hendra virus belong to the Paramyxoviridae family. “While the members of this group of viruses are only responsible for a few limited outbreaks, the ability of these viruses to infect a wide range of hosts and cause a disease leading to high fatalities in humans has made them a public health concern,” stated the WHO.
 

Related to measles

The research team identified LayV while monitoring patients at three hospitals in the eastern Chinese provinces of Shandong and Henan between April 2018 and August 2021. Throughout the study period, the researchers found 35 people infected with LayV, mostly farmers, with symptoms ranging from a cough to severe pneumonia. Participants were recruited into the study if they had a fever. The team sequenced the LayV genome from a throat swab taken from the first patient identified with the disease, a 53-year-old woman.

The LayV genome showed that the virus is most closely related to Mojiang henipavirus, which was first isolated in rats in an abandoned mine in the southern Chinese province of Yunnan in 2012. Henipaviruses belong to the Paramyxoviridae family of viruses, which includes measles, mumps, and many respiratory viruses that infect humans. Several other henipaviruses have been discovered in bats, rats, and shrews from Australia to South Korea and China, but only Hendra, Nipah, and now LayV are known to infect people, according to Nature.
 

Animal origin likely

Because most patients stated in a questionnaire that they had been exposed to an animal during the month preceding the onset of their symptoms, the researchers tested goats, dogs, pigs, and cattle living in the villages of infected patients for antibodies against LayV. They found LayV antibodies in a handful of goats and dogs and identified LayV viral RNA in 27% of the 262 sampled shrews. These findings suggest that the shrew may be a natural reservoir of LayV, passing it between themselves “and somehow infecting people here and there by chance,” Emily Gurley, PhD, MPH, an infectious diseases epidemiologist at Johns Hopkins University, Baltimore, told Nature.

The researchers did not find strong evidence of LayV spreading between the people included in the study. There were no clusters of cases in the same family, within a short time span, or in close geographical proximity. “Of the 35 cases, not a single one is linked,” said Dr. Wang, which Dr. Gurley considered good news. It should be noted, however ,”that the study did retrospective contact tracing on only 15 family members of nine infected individuals, which makes it difficult to determine how exactly the individuals were exposed,” reported Nature.
 

Vigilance is needed

Should we be worried about a potential new epidemic? The replies from two experts interviewed by Nature were reassuring. “There is no particular need to worry about this virus, but ongoing surveillance is critical,” said Professor Edward Holmes, an evolutionary virologist at the University of Sydney. Regularly testing people and animals for emerging viruses is important to understand the risk for zoonotic diseases – those that can be transmitted from other animals to humans, he said.

It is still not clear how people were infected in the first place – whether directly from shrews or an intermediate animal, said Dr. Gurley. That’s why a lot of research still needs to be done to work out how the virus is spreading in shrews and how people are getting infected, she added.

Nevertheless, Dr. Gurley finds that large outbreaks of infectious diseases typically take off after a lot of false starts. “If we are actively looking for those sparks, then we are in a much better position to stop or to find something early.” Still, she noted that she didn’t see anything in the data to “cause alarm from a pandemic-threat perspective.”

Though there is not currently any cause for worry of a new pandemic, vigilance is crucial. Professor Holmes says there is an urgent need for a global surveillance system to detect virus spillovers and rapidly communicate those results to avoid more pandemics, such as the one sparked by COVID-19. “These sorts of zoonotic spillover events happen all the time,” he said. “The world needs to wake up.”

This article was translated from the Medscape French edition. A version appeared on Medscape.com.

Between 2018 and August 2022, Chinese researchers identified 35 people infected with a new animal virus in eastern China. These cases were reported in The New England Journal of Medicine. When asked by Nature about this emerging virus that has until now flown under the radar, scientists said that they were not overly concerned because the virus doesn’t seem to spread easily between people nor is it fatal.

Researchers think that the virus is carried by shrews. It might have infected people directly or through an intermediate animal.
 

First identified in Langya

The authors describe 35 cases of infection with a virus called Langya henipavirus (LayV) since 2018. It is closely related to two other henipaviruses known to infect people – Hendra virus and Nipah virus. The virus was named Langya after the town in Shandong province in China where the first patient identified with the disease was from, explained coauthor Linfa Wang, PhD, a virologist at Duke-NUS Medical School, Singapore.

Langya can cause respiratory symptoms such as fever, cough, and fatigue. Hendra virus and Nipah virus also cause respiratory infections and can be fatal, the article in Nature reports.
 

Hendra and Nipah

According to the World Health Organization, Nipah virus, which was discovered in 1999, is a new virus responsible for a zoonosis that causes the disease in animals and humans who have had contact with infected animals. Its name comes from the location where it was first identified in Malaysia. Patients may have asymptomatic infection or symptoms such as acute respiratory infection and severe encephalitis. The case fatality rate is between 40% and 75%.

Nipah virus is closely related to another recently discovered (1994) zoonotic virus called Hendra virus, which is named after the Australian city in which it first appeared. On that day in July 2016, 53 cases were identified involving 70 horses. These incidents remained confined to the northeastern coast of Australia.

Nipah virus and Hendra virus belong to the Paramyxoviridae family. “While the members of this group of viruses are only responsible for a few limited outbreaks, the ability of these viruses to infect a wide range of hosts and cause a disease leading to high fatalities in humans has made them a public health concern,” stated the WHO.
 

Related to measles

The research team identified LayV while monitoring patients at three hospitals in the eastern Chinese provinces of Shandong and Henan between April 2018 and August 2021. Throughout the study period, the researchers found 35 people infected with LayV, mostly farmers, with symptoms ranging from a cough to severe pneumonia. Participants were recruited into the study if they had a fever. The team sequenced the LayV genome from a throat swab taken from the first patient identified with the disease, a 53-year-old woman.

The LayV genome showed that the virus is most closely related to Mojiang henipavirus, which was first isolated in rats in an abandoned mine in the southern Chinese province of Yunnan in 2012. Henipaviruses belong to the Paramyxoviridae family of viruses, which includes measles, mumps, and many respiratory viruses that infect humans. Several other henipaviruses have been discovered in bats, rats, and shrews from Australia to South Korea and China, but only Hendra, Nipah, and now LayV are known to infect people, according to Nature.
 

Animal origin likely

Because most patients stated in a questionnaire that they had been exposed to an animal during the month preceding the onset of their symptoms, the researchers tested goats, dogs, pigs, and cattle living in the villages of infected patients for antibodies against LayV. They found LayV antibodies in a handful of goats and dogs and identified LayV viral RNA in 27% of the 262 sampled shrews. These findings suggest that the shrew may be a natural reservoir of LayV, passing it between themselves “and somehow infecting people here and there by chance,” Emily Gurley, PhD, MPH, an infectious diseases epidemiologist at Johns Hopkins University, Baltimore, told Nature.

The researchers did not find strong evidence of LayV spreading between the people included in the study. There were no clusters of cases in the same family, within a short time span, or in close geographical proximity. “Of the 35 cases, not a single one is linked,” said Dr. Wang, which Dr. Gurley considered good news. It should be noted, however ,”that the study did retrospective contact tracing on only 15 family members of nine infected individuals, which makes it difficult to determine how exactly the individuals were exposed,” reported Nature.
 

Vigilance is needed

Should we be worried about a potential new epidemic? The replies from two experts interviewed by Nature were reassuring. “There is no particular need to worry about this virus, but ongoing surveillance is critical,” said Professor Edward Holmes, an evolutionary virologist at the University of Sydney. Regularly testing people and animals for emerging viruses is important to understand the risk for zoonotic diseases – those that can be transmitted from other animals to humans, he said.

It is still not clear how people were infected in the first place – whether directly from shrews or an intermediate animal, said Dr. Gurley. That’s why a lot of research still needs to be done to work out how the virus is spreading in shrews and how people are getting infected, she added.

Nevertheless, Dr. Gurley finds that large outbreaks of infectious diseases typically take off after a lot of false starts. “If we are actively looking for those sparks, then we are in a much better position to stop or to find something early.” Still, she noted that she didn’t see anything in the data to “cause alarm from a pandemic-threat perspective.”

Though there is not currently any cause for worry of a new pandemic, vigilance is crucial. Professor Holmes says there is an urgent need for a global surveillance system to detect virus spillovers and rapidly communicate those results to avoid more pandemics, such as the one sparked by COVID-19. “These sorts of zoonotic spillover events happen all the time,” he said. “The world needs to wake up.”

This article was translated from the Medscape French edition. A version appeared on Medscape.com.

Between 2018 and August 2022, Chinese researchers identified 35 people infected with a new animal virus in eastern China. These cases were reported in The New England Journal of Medicine. When asked by Nature about this emerging virus that has until now flown under the radar, scientists said that they were not overly concerned because the virus doesn’t seem to spread easily between people nor is it fatal.

Researchers think that the virus is carried by shrews. It might have infected people directly or through an intermediate animal.
 

First identified in Langya

The authors describe 35 cases of infection with a virus called Langya henipavirus (LayV) since 2018. It is closely related to two other henipaviruses known to infect people – Hendra virus and Nipah virus. The virus was named Langya after the town in Shandong province in China where the first patient identified with the disease was from, explained coauthor Linfa Wang, PhD, a virologist at Duke-NUS Medical School, Singapore.

Langya can cause respiratory symptoms such as fever, cough, and fatigue. Hendra virus and Nipah virus also cause respiratory infections and can be fatal, the article in Nature reports.
 

Hendra and Nipah

According to the World Health Organization, Nipah virus, which was discovered in 1999, is a new virus responsible for a zoonosis that causes the disease in animals and humans who have had contact with infected animals. Its name comes from the location where it was first identified in Malaysia. Patients may have asymptomatic infection or symptoms such as acute respiratory infection and severe encephalitis. The case fatality rate is between 40% and 75%.

Nipah virus is closely related to another recently discovered (1994) zoonotic virus called Hendra virus, which is named after the Australian city in which it first appeared. On that day in July 2016, 53 cases were identified involving 70 horses. These incidents remained confined to the northeastern coast of Australia.

Nipah virus and Hendra virus belong to the Paramyxoviridae family. “While the members of this group of viruses are only responsible for a few limited outbreaks, the ability of these viruses to infect a wide range of hosts and cause a disease leading to high fatalities in humans has made them a public health concern,” stated the WHO.
 

Related to measles

The research team identified LayV while monitoring patients at three hospitals in the eastern Chinese provinces of Shandong and Henan between April 2018 and August 2021. Throughout the study period, the researchers found 35 people infected with LayV, mostly farmers, with symptoms ranging from a cough to severe pneumonia. Participants were recruited into the study if they had a fever. The team sequenced the LayV genome from a throat swab taken from the first patient identified with the disease, a 53-year-old woman.

The LayV genome showed that the virus is most closely related to Mojiang henipavirus, which was first isolated in rats in an abandoned mine in the southern Chinese province of Yunnan in 2012. Henipaviruses belong to the Paramyxoviridae family of viruses, which includes measles, mumps, and many respiratory viruses that infect humans. Several other henipaviruses have been discovered in bats, rats, and shrews from Australia to South Korea and China, but only Hendra, Nipah, and now LayV are known to infect people, according to Nature.
 

Animal origin likely

Because most patients stated in a questionnaire that they had been exposed to an animal during the month preceding the onset of their symptoms, the researchers tested goats, dogs, pigs, and cattle living in the villages of infected patients for antibodies against LayV. They found LayV antibodies in a handful of goats and dogs and identified LayV viral RNA in 27% of the 262 sampled shrews. These findings suggest that the shrew may be a natural reservoir of LayV, passing it between themselves “and somehow infecting people here and there by chance,” Emily Gurley, PhD, MPH, an infectious diseases epidemiologist at Johns Hopkins University, Baltimore, told Nature.

The researchers did not find strong evidence of LayV spreading between the people included in the study. There were no clusters of cases in the same family, within a short time span, or in close geographical proximity. “Of the 35 cases, not a single one is linked,” said Dr. Wang, which Dr. Gurley considered good news. It should be noted, however ,”that the study did retrospective contact tracing on only 15 family members of nine infected individuals, which makes it difficult to determine how exactly the individuals were exposed,” reported Nature.
 

Vigilance is needed

Should we be worried about a potential new epidemic? The replies from two experts interviewed by Nature were reassuring. “There is no particular need to worry about this virus, but ongoing surveillance is critical,” said Professor Edward Holmes, an evolutionary virologist at the University of Sydney. Regularly testing people and animals for emerging viruses is important to understand the risk for zoonotic diseases – those that can be transmitted from other animals to humans, he said.

It is still not clear how people were infected in the first place – whether directly from shrews or an intermediate animal, said Dr. Gurley. That’s why a lot of research still needs to be done to work out how the virus is spreading in shrews and how people are getting infected, she added.

Nevertheless, Dr. Gurley finds that large outbreaks of infectious diseases typically take off after a lot of false starts. “If we are actively looking for those sparks, then we are in a much better position to stop or to find something early.” Still, she noted that she didn’t see anything in the data to “cause alarm from a pandemic-threat perspective.”

Though there is not currently any cause for worry of a new pandemic, vigilance is crucial. Professor Holmes says there is an urgent need for a global surveillance system to detect virus spillovers and rapidly communicate those results to avoid more pandemics, such as the one sparked by COVID-19. “These sorts of zoonotic spillover events happen all the time,” he said. “The world needs to wake up.”

This article was translated from the Medscape French edition. A version appeared on Medscape.com.