Clinical and virological features of first human monkeypox cases in Germany

Abstract

Background: Monkeypox is a zoonotic orthopoxvirus infection endemic in central and western Africa. In May 2022, human monkeypox infections including human-to-human transmission were reported in a multi-country outbreak in Europe and North America.

Case presentations: Here we present the first two cases of monkeypox infection in humans diagnosed in Germany. We present clinical and virological findings, including the detection of monkeypox virus DNA in blood and semen. The clinical presentation and medical history of our patients suggest close physical contact during sexual interactions as the route of infection.

Conclusion: Monkeypox requires rapid diagnosis and prompt public health response. The disease should be considered in the current situation especially the differential diagnosis of vesicular or pustular rash, particularly in patients with frequent sexual contacts. Most importantly, it is essential to raise awareness among all health professionals for the rapid and correct recognition and diagnosis of this disease, which is probably still underreported in Europe (Adler et al. in Lancet Infect Dis https://doi.org/10.1016/s1473-3099(22)00228-6 , 2022).

Keywords: Blood; Efflorescence; Germany; HIV; Monkeypox; Semen; Skin lesion.

Fig. 1

A Enoral lesions (right tonsil) visible already at first presentation of patient #1. B–D Both patients developed 10–12 initially vesicular, later pustular skin lesions distributed over the entire body. Many of these lesions were umbilicated, and all were at the same general stage of development. Upon opening of the lesions, the typical septate structure of pox lesions became apparent

Fig. 2

Histogram plot of MPXV genome copies per mL found in patient samples. Genome copies/mL of the two patients were averaged per sample type. Copy number per mL was determined using a linear dilution series of a quantified MPXV DNA standard

Fig. 3

Isolation of MPXV-IMBmuc1 on Vero E6 cells and serology results. VeroE6 cells were inoculated with sample material from a lanced pustule of Patient #1 following standard procedure [17]. A Typical plaque formation of MPXV IMBmuc 1 on Vero E6 2 days post-infection of the sample material. B Vero E6 mock infected. C Plaque morphology of vaccinia virus (VACV) Elstree (1), VACV WR (2), MPXV IMBmuc 1 (3; most similar to VACV Elstree), MPXV IMBdrc 2510 (4), on MA104 cells 3 dpi—size bar refers to (1–4). D Reactivity of VACV Elstree in immunofluorescence assay with sera from patient #1 at hospital admission (1; non-reactive) and 11 days later (2; reactive, titre 80), sera of MVA unvaccinated (3; non-reactive), and MVA vaccinated (4; reactive) controls

Fig. 4

Maximum-likelihood tree based on selection of full genome sequences of MPXV. Genome sequence of MPXV-IMBmuc1 was obtained from direct sequencing of clinical material using Illumina-short read technology and subsequent de-novo assembly. A selection of full genomes of MPXV classified as West-African-clade as well as isolate Zaire-96-I-16 were used for alignment of this new sequence with phylogenetic grouping. The calculated tree was rooted at the separation between the Central and West African clades. German patient sequence marked with a green dot