病史和体格检查
关键诊断因素
常见
皮疹/病损
患者的特征性皮疹通常始于面部和身体,并通过离心方式扩散到手掌和脚底(此前 24 h 中可能会出现累及口咽和舌的皮疹)。病损同时进展,经过四个阶段——斑疹、丘疹、水疱和脓疱期,然后结痂、消退。病损直径通常为 5-10 mm,可能呈离散或融合性,数量可能很少或达数千个。水疱边界清晰,位于真皮深处。皮疹通常在 2-4 周内消退。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 [28]World Health Organization. Mpox (monkeypox): fact sheet. Apr 2023 [internet publication]. https://www.who.int/en/news-room/fact-sheets/detail/monkeypox [89]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988. http://apps.who.int/iris/handle/10665/39485 [169]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7. https://academic.oup.com/cid/article/58/2/260/335791 http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com [185]Centers for Disease Control and Prevention. Mpox: clinical recognition. Aug 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
在 2022 年全球暴发中,这种表现不典型,皮疹主要出现在肛门生殖器区域。[54]Sukhdeo S, Mishra S, Walmsley S. Human monkeypox: a comparison of the characteristics of the new epidemic to the endemic disease. BMC Infect Dis. 2022 Dec 12;22(1):928. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9742013 http://www.ncbi.nlm.nih.gov/pubmed/36503476?tool=bestpractice.com 病损往往局限于生殖器、会阴/肛周或口周区域,通常不会进一步扩散。[68]World Health Organization. Multi-country monkeypox outbreak: situation update. 27 June 2022 [internet publication]. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396 [185]Centers for Disease Control and Prevention. Mpox: clinical recognition. Aug 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html [197]Girometti N, Byrne R, Bracchi M, et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. Lancet Infect Dis. 2022 Sep;22(9):1321-8. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00411-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/35785793?tool=bestpractice.com [198]European Centre for Disease Prevention and Control. Monkeypox cases reported in UK and Portugal. May 2022 [internet publication]. https://www.ecdc.europa.eu/en/news-events/monkeypox-cases-reported-uk-and-portugal [199]Patrocinio-Jesus R, Peruzzu F. Monkeypox genital lesions. N Engl J Med. 2022 Jul 7;387(1):66. https://www.nejm.org/doi/10.1056/NEJMicm2206893 http://www.ncbi.nlm.nih.gov/pubmed/35704421?tool=bestpractice.com [200]Orviz E, Negredo A, Ayerdi O, et al. Monkeypox outbreak in Madrid (Spain): clinical and virological aspects. J Infect. 2022 Oct;85(4):412-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9534097 http://www.ncbi.nlm.nih.gov/pubmed/35830908?tool=bestpractice.com [201]Català A, Clavo Escribano P, Riera J, et al. Monkeypox outbreak in Spain: clinical and epidemiological findings in a prospective cross-sectional study of 185 cases. Br J Dermatol. 2022 Nov;187(5):765-72. https://onlinelibrary.wiley.com/doi/10.1111/bjd.21790 http://www.ncbi.nlm.nih.gov/pubmed/35917191?tool=bestpractice.com 其他不典型表现包括:仅出现数处病损(甚至只有单处病损),而且可能不呈播散性表现;无皮损,但有肛门疼痛和出血;病损处于不同发展阶段(不同步);皮疹不一定出现于手掌和足底;病损出现于前驱症状之前。[68]World Health Organization. Multi-country monkeypox outbreak: situation update. 27 June 2022 [internet publication]. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396 [185]Centers for Disease Control and Prevention. Mpox: clinical recognition. Aug 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html [187]Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul 28;378:e072410. https://www.bmj.com/content/378/bmj-2022-072410 http://www.ncbi.nlm.nih.gov/pubmed/35902115?tool=bestpractice.com [202]Quattri E, Avallone G, Maronese CA, et al. Unilesional monkeypox: a report of two cases from Italy. Travel Med Infect Dis. 2022 Aug 10;49:102424. https://www.sciencedirect.com/science/article/pii/S1477893922001703 http://www.ncbi.nlm.nih.gov/pubmed/35961491?tool=bestpractice.com 据报道,有女性患者出现局部外阴、阴道内和宫颈病损。[207]Portela-Dias J, Sereno S, Falcão-Reis I, et al. Female monkeypox infection with localized genital lesions. Am J Obstet Gynecol. 2022 Aug 25 [Epub ahead of print]. https://www.ajog.org/article/S0002-9378(22)00689-5/pdf http://www.ncbi.nlm.nih.gov/pubmed/36030847?tool=bestpractice.com [208]Vallée A, Chatelain A, Carbonnel M, et al. Monkeypox virus infection in 18-year-old woman after sexual intercourse, France, September 2022. Emerg Infect Dis. 2022 Nov 10;29(1). https://wwwnc.cdc.gov/eid/article/29/1/22-1643_article http://www.ncbi.nlm.nih.gov/pubmed/36355630?tool=bestpractice.com [209]Zayat N, Huang S, Wafai J, et al. Monkeypox virus infection in 22-year-old woman after sexual intercourse, New York, USA. Emerg Infect Dis. 2022 Nov 10;29(1). https://wwwnc.cdc.gov/eid/article/29/1/22-1662_article http://www.ncbi.nlm.nih.gov/pubmed/36355634?tool=bestpractice.com [210]Ramírez M, Delso V, Sánchez MJ, et al. Mpox (monkeypox) presenting as cervical and vulvar disease. Obstet Gynecol. 2023 Jan 10 [Epub ahead of print]. https://journals.lww.com/greenjournal/Fulltext/9900/Mpox__Monkeypox__Presenting_as_Cervical_and_Vulvar.671.aspx http://www.ncbi.nlm.nih.gov/pubmed/36626748?tool=bestpractice.com 据报道,在 2022 年全球暴发中,95.2% 的患者出现了皮疹/病损。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
据报道,在 2022 年全球暴发中,一些患者出现了红色斑丘疹性、全身紫癜性和麻疹样皮疹。[187]Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul 28;378:e072410. https://www.bmj.com/content/378/bmj-2022-072410 http://www.ncbi.nlm.nih.gov/pubmed/35902115?tool=bestpractice.com [211]Prasad S, Casas CG, Strahan AG, et al. A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: skin lesion morphology, clinical course, and scarring. J Am Acad Dermatol. 2023 Jan 11 [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9833815 http://www.ncbi.nlm.nih.gov/pubmed/36641010?tool=bestpractice.com [213]Simon-Gozalbo A, Gamo-Guerrero M, Alonso-Garcia S, et al. Haemorrhagic monkeypox infection in an immunosuppressed patient with human immunodeficiency virus: beyond the pustules. Clin Microbiol Infect. 2023 Jan;29(1):122-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9534161 http://www.ncbi.nlm.nih.gov/pubmed/36206864?tool=bestpractice.com
依据病损数量,可以确定皮损的严重程度:轻度(<25 处皮损);中度(25-99 处皮损);重度(100-250 处皮损);极重度(>250 处皮损)。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 大多数患者(64%)有 <10 处病损,2022 年全球暴发中大约 10% 的患者只有一处生殖器病变。[99]Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox virus infection in humans across 16 countries: April–June 2022. N Engl J Med. 2022 Aug 25;387(8):679-91. https://www.nejm.org/doi/full/10.1056/NEJMoa2207323 http://www.ncbi.nlm.nih.gov/pubmed/35866746?tool=bestpractice.com
病损最初可能很疼痛,在愈合阶段会瘙痒。外生殖器病损可引发严重肿胀和疼痛。口腔病损可能引起进食和饮水困难,从而可能导致脱水和营养不良。请参阅并发症。
世界卫生组织发布了一份 mpox 病变图册,展示了病变的示例。 WHO: atlas of mpox lesions - a tool for clinical researchers Opens in new window
肛门直肠症状
肛门直肠症状是 2022 年全球暴发特有的表现,以往并无相关描述。[29]Li P, Li J, Ayada I, et al. Clinical features, antiviral treatment and patient outcomes: a systematic review and comparative analysis of the previous and the 2022 mpox outbreaks. J Infect Dis. 2023 Feb 3 [Epub ahead of print]. https://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiad034/7025706?login=false http://www.ncbi.nlm.nih.gov/pubmed/36735342?tool=bestpractice.com [55]Hatami H, Jamshidi P, Arbabi M, et al. Demographic, epidemiologic, and clinical characteristics of human Monkeypox disease pre- and post-2022 Outbreaks: a systematic review and meta-analysis. Biomedicines. 2023 Mar 20;11(3):957. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10045775 http://www.ncbi.nlm.nih.gov/pubmed/36979936?tool=bestpractice.com
部分患者可表现为严重/剧烈的肛门直肠疼痛(包括排便时的严重疼痛)、里急后重、直肠出血,或与肛周/直肠病损和直肠炎相关的脓性便或血便。患者可能没有皮疹。[185]Centers for Disease Control and Prevention. Mpox: clinical recognition. Aug 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html [186]Philpott D, Hughes CM, Alroy KA, et al. Epidemiologic and clinical characteristics of monkeypox cases: United States, May 17 – July 22, 2022. MMWR Morb Mortal Wkly Rep. 2022 Aug 12;71(32):1018-22. https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e3.htm http://www.ncbi.nlm.nih.gov/pubmed/35951487?tool=bestpractice.com [187]Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul 28;378:e072410. https://www.bmj.com/content/378/bmj-2022-072410 http://www.ncbi.nlm.nih.gov/pubmed/35902115?tool=bestpractice.com [189]Centers for Disease Control and Prevention. Updated case-finding guidance: monkeypox outbreak - United States, 2022. Jun 2022 [internet publication]. https://emergency.cdc.gov/han/2022/han00468.asp [190]Pfäfflin F, Wendisch D, Scherer R, et al. Monkeypox in-patients with severe anal pain. Infection. 2022 Aug 12 [Epub ahead of print]. https://link.springer.com/article/10.1007/s15010-022-01896-7 http://www.ncbi.nlm.nih.gov/pubmed/35960457?tool=bestpractice.com [191]Yakubovsky M, Shasha D, Reich S, et al. Monkeypox presenting as proctitis in men who have sex with men. Clin Infect Dis. 2022 Sep 6 [Epub ahead of print]. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciac737/6692817 http://www.ncbi.nlm.nih.gov/pubmed/36066470?tool=bestpractice.com 其他肛门症状可能包括瘙痒、大便困难、烧灼感、肿胀和黏液分泌物。[192]Rekik S, Pluart DL, Ferré V, et al. Anogenital symptoms and lesions in a series of 20 patients infected with monkeypox virus. Colorectal Dis. 2023 Feb 8 [Epub ahead of print]. https://onlinelibrary.wiley.com/doi/10.1111/codi.16513 http://www.ncbi.nlm.nih.gov/pubmed/36756717?tool=bestpractice.com
来自 2022 年全球暴发的数据表明,65.7% 的患者有肛门生殖器病损,18.5% 的患者有直肠炎或肛门直肠疼痛。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
进行被动肛交性行为的男性比未进行被动肛交性行为的男性更常出现直肠炎。[193]Tarín-Vicente EJ, Alemany A, Agud-Dios M, et al. Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. Lancet. 2022 Aug 27;400(10353):661-9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01436-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/35952705?tool=bestpractice.com
这种表现易与一些 STI 或直肠炎的其他病因相混淆。[189]Centers for Disease Control and Prevention. Updated case-finding guidance: monkeypox outbreak - United States, 2022. Jun 2022 [internet publication]. https://emergency.cdc.gov/han/2022/han00468.asp
发热
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,发热见于 85% 的病例,寒战见于 71% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
2022 年全球暴发中有 58.4% 的患者有此报告(23.8% 出现寒战)。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
淋巴结肿大
可呈全身性,或者局限于若干区域。通常在皮疹之前伴随发热出现,或者罕见情况下,伴随皮疹出现。可出现于颌下和颈部、腋下或腹股沟,并出现于躯体两侧或仅仅一侧。[185]Centers for Disease Control and Prevention. Mpox: clinical recognition. Aug 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html 腹股沟淋巴结肿大是 2022 年全球暴发中最常见的表现(47%)。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
肿大的淋巴结直径约为 1 至 4 cm,质地坚硬,伴触痛,有时可呈现疼痛。
淋巴结肿大是一种常见的鉴别特征,在患天花和鉴别诊断中的其他疾病时罕见。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 [45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com [89]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988. http://apps.who.int/iris/handle/10665/39485 [169]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7. https://academic.oup.com/cid/article/58/2/260/335791 http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
2022 年全球暴发中有 53% 的患者有此报告。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
有疼痛的颈部淋巴结肿大所致吞咽困难可能是重度疾病或有并发症疾病的一种征象。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 已有关于可发生阻塞(例如,气道内)或坏死的重度淋巴结肿大的报道。[184]Centers for Disease Control and Prevention. Health alert network (HAN) health advisory: severe manifestations of monkeypox among people who are immunocompromised due to HIV or other conditions. September 2022 [internet publication]. https://emergency.cdc.gov/han/2022/han00475.asp
其他诊断因素
常见
疲劳/虚弱/周身不适
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
2022 年全球暴发中有 38.7% 的患者有此报告。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
肌痛
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,肌痛见于 56% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
2022 年全球暴发中有 30.8% 的患者有此报告。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
头痛
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,头痛见于 65% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
2022 年全球暴发中有 29.5% 的患者有此报告。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
咽痛
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
口咽部症状可能引起剧烈疼痛或吞咽困难(吞咽痛)。
据以往的报道,咽炎见于 60% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
2022 年全球暴发中有 23.4% 的患者报告咽痛/吞咽痛。11.8% 的患者报告吞咽困难。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
背痛
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,背痛见于 30% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
2022 年全球暴发中有 8.1% 的患者有此报告。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
咳嗽
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
2022 年全球暴发中有 7.3% 的患者有此报告。[18]Liu Q, Fu L, Wang B, et al. Clinical characteristics of human mpox (monkeypox) in 2022: a systematic review and meta-analysis. Pathogens. 2023 Jan 15;12(1):146. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9861547 http://www.ncbi.nlm.nih.gov/pubmed/36678494?tool=bestpractice.com
恶心/呕吐
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,恶心/呕吐见于 32% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
可能导致严重脱水,可能是重度疾病或有并发症疾病的一种征象。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
不常见
腹泻
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,腹泻见于 6% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
可导致严重脱水。
谵妄/意识模糊
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,意识模糊见于 6% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
可能是重度疾病或有并发症疾病的一种征象。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
癫痫发作
通常为前驱期症状(常出现于皮疹之前),但亦可在皮疹之后出现,或根本不出现。
据以往的报道,抽搐见于 3% 的病例。[45]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51. https://academic.oup.com/cid/article/41/12/1742/344953 http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
危险因素
强
近期到访/居住于流行国家或疫情暴发国家
患者可能报告近期到访(或居住于)流行国家(中非或西非),或者在症状出现之前 21 日内到访(或居住于)正经历疫情暴发的国家。
目前多个国家正在经历全球性疫情暴发。有关当前受疫情影响地点的更多信息,请咨询公共卫生机构。
WHO: 2022-23 mpox (monkeypox) outbreak - global trends Opens in new window
接触疑诊、拟诊或确诊病例
人际传播很少发生,但已经报告了连续传播事件,目前多个国家正在发生涉及人际传播的全球性疫情暴发。[6]Bunge EM, Hoet B, Chen L, et al. The changing epidemiology of human monkeypox – a potential threat? A systematic review. PLoS Negl Trop Dis. 2022 Feb;16(2):e0010141. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8870502 http://www.ncbi.nlm.nih.gov/pubmed/35148313?tool=bestpractice.com [103]Nolen LD, Osadebe L, Katomba J, et al. Introduction of monkeypox into a community and household: risk factors and zoonotic reservoirs in the Democratic Republic of the Congo. Am J Trop Med Hyg. 2015 Aug;93(2):410-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530773 http://www.ncbi.nlm.nih.gov/pubmed/26013374?tool=bestpractice.com 40-50 岁以下者(取决于国家)可能更易感,原因在于根除天花之后,全世界均已停止常规天花疫苗接种。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
在 2022 年全球暴发期间,认为新近受波及国家/地区中一般人群的风险较低,而过去发生过传播的国家/地区(及其邻国)中一般人群的风险为中等。[14]World Health Organization. 2022-23 mpox (monkeypox) outbreak: global trends. Nov 2023 [internet publication]. https://worldhealthorg.shinyapps.io/mpx_global
世界卫生组织将接触者定义为,在传染期(即从指示病例首发症状发作开始,到皮损已结痂、结痂脱落以及下方形成一层新鲜皮层时结束)接触过感染者,并与很可能或确诊病例发生过以下一种或多种暴露(包括在没有恰当使用适当个人防护装备的情况下可能暴露的卫生工作者):直接皮肤-皮肤和皮肤-黏膜或口腔-黏膜的机体接触;接触被污染材料;长期面对面的呼吸道暴露,距离很近;或呼吸道暴露或眼黏膜暴露于感染者的病变材料。[107]World Health Organization. Surveillance, case investigation and contact tracing for mpox (monkeypox): interim guidance, 22 December 2022. December 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2022.4
各地区病例定义有所不同。咨询当地公共卫生部门,获取更多信息和指导。参阅 诊断标准。
职业暴露
医务工作者的总体感染风险较低(无论有无适当的个人防护装备)。对于没有适当的个人防护设备而要执行产生气溶胶操作的医务工作者,该风险为中等。[73]European Centre for Disease Prevention and Control. Monkeypox multi-country outbreak: second update. October 2022 [internet publication]. https://www.ecdc.europa.eu/en/publications-data/monkeypox-multi-country-outbreak-second-update
据报道,在 2022 年多国暴发中,卫生工作者中出现了少数猴痘病例,其中多数病例是在社区发生感染,而非通过职业暴露感染。[14]World Health Organization. 2022-23 mpox (monkeypox) outbreak: global trends. Nov 2023 [internet publication]. https://worldhealthorg.shinyapps.io/mpx_global
在实践中,即使不完全遵循建议穿戴推荐的个人防护装备,医务工作者的风险似乎也非常低。[108]Marshall KE, Barton M, Nichols J, et al. Health care personnel exposures to subsequently laboratory-confirmed monkeypox patients: Colorado, 2022. MMWR Morb Mortal Wkly Rep. 2022 Sep 23;71(38):1216-9. https://www.cdc.gov/mmwr/volumes/71/wr/mm7138e2.htm http://www.ncbi.nlm.nih.gov/pubmed/36136939?tool=bestpractice.com [109]Marshall KE, Barton M, Nichols J, et al. Health care personnel exposures to subsequently laboratory-confirmed monkeypox patients: Colorado, 2022. Am J Transplant. 2022 Nov;22(11):2699-703. https://onlinelibrary.wiley.com/doi/10.1111/ajt.16681 http://www.ncbi.nlm.nih.gov/pubmed/36346086?tool=bestpractice.com 然而,已有通过针刺伤传播的报道,而这可能是通过污染物传播。[110]Safir A, Safir M, Henig O, et al. Nosocomial transmission of MPOX virus to health care workers -an emerging occupational hazard: A case report and review of the literature. Am J Infect Control. 2023 Feb 2 [Epub ahead of print]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9891803 http://www.ncbi.nlm.nih.gov/pubmed/36736902?tool=bestpractice.com
由于存在口咽部病变,牙医(和牙科助理)可能是首先发现症状的人,并且有可能在牙科手术中产生飞沫和气溶胶。[111]Szkiela M, Wiszniewska M, Lipińska-Ojrzanowska A. Monkeypox (Mpox) and occupational exposure. Int J Environ Res Public Health. 2023 Mar 14;20(6):5087. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10049490 http://www.ncbi.nlm.nih.gov/pubmed/36981996?tool=bestpractice.com
在教育机构接触确诊病例后的工作人员和学生中,该风险似乎很低。[112]Ladhani SN, Aiano F, Edwards DS, et al. Very low risk of monkeypox among staff and students after exposure to a confirmed case in educational settings, England, May to July 2022. Euro Surveill. 2022 Oct;27(40). https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.40.2200734 http://www.ncbi.nlm.nih.gov/pubmed/36205169?tool=bestpractice.com
一次性的随机性行为或有多名性伴侣
在 2022 年全球暴发中,绝大多数病例为报告有多名性伴侣(通常在过去 3 个月内有 5 名或以上)的男男性行为者。[58]UK Health Security Agency. Research and analysis Mpox: transmission, and infectious and incubation periods. Mar 2023 [internet publication]. https://www.gov.uk/government/publications/mpox-transmission-and-infectious-and-incubation-periods 目前认为男男性行为者和性工作者的总体风险为中等。[14]World Health Organization. 2022-23 mpox (monkeypox) outbreak: global trends. Nov 2023 [internet publication]. https://worldhealthorg.shinyapps.io/mpx_global
近期纹身或穿孔
2022 年全球暴发中已有与穿孔和纹身店(包括 microblading,一种用于纹眉的半永久性纹身技术)相关的暴发报道。在一次暴发中,37% 的接触者发生感染,而且多数病例的纹身/穿孔部位出现皮疹。[113]Tascini C, Geminiani M, Sbrana F, et al. Possible tattoo-transmitted monkeypox viral infection. Intern Emerg Med. 2022 Nov;17(8):2421-2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9652165 http://www.ncbi.nlm.nih.gov/pubmed/36112319?tool=bestpractice.com [114]Del Río García V, Palacios JG, Morcillo AM, et al. Monkeypox outbreak in a piercing and tattoo establishment in Spain. Lancet Infect Dis. 2022 Sep 29;22(11):1526-8. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00652-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36183706?tool=bestpractice.com [115]Castaño-Fernández JL, Grau-Pérez M. Microblading-transmitted Monkeypox infection: fomites matter. Br J Dermatol. 2023 Mar 11[Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/36899480?tool=bestpractice.com [116]Beaumont AL, Raphaël E, Bertin C, et al. Mpox lesions on a tattoo. Lancet Infect Dis. 2023 Jun;23(6):762. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00795-2/fulltext
接触感染动物
动物宿主可能是人类感染的最初来源,尤其是在流行疫区。可能有与来自非洲的非人类灵长类动物或啮齿类动物(例如松鼠、大鼠、睡鼠)接触的既往史。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 由于西非和中非存在动物宿主,因此猴痘很难根除。
可能感染 mpox 的动物包括草原犬鼠、松鼠、旱獭和土拨鼠、毛丝鼠、巨囊鼠、刺猬、鼩鼱、猴和猿。小鼠、大鼠和家兔都有可能被感染,但这可能因种属而异。目前尚不清楚其他动物(如狗、猫、沙鼠、豚鼠、仓鼠、家畜和农场动物、野生动物)是否会受到感染。[117]Centers for Disease Control and Prevention. Mpox in animals and pets. Aug 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/veterinarian/monkeypox-in-animals.html
建立地方性动物病循环和向人类溢出事件的风险被认为较低。[73]European Centre for Disease Prevention and Control. Monkeypox multi-country outbreak: second update. October 2022 [internet publication]. https://www.ecdc.europa.eu/en/publications-data/monkeypox-multi-country-outbreak-second-update
儿童(重症)
儿童罹患重症的风险可能增加。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 [7]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577 http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com [89]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988. http://apps.who.int/iris/handle/10665/39485 在既往暴发中,患者多为儿童。[29]Li P, Li J, Ayada I, et al. Clinical features, antiviral treatment and patient outcomes: a systematic review and comparative analysis of the previous and the 2022 mpox outbreaks. J Infect Dis. 2023 Feb 3 [Epub ahead of print]. https://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiad034/7025706?login=false http://www.ncbi.nlm.nih.gov/pubmed/36735342?tool=bestpractice.com 然而,来自 2022 年全球暴发的现有证据表明,儿童病例罕见,并且其临床表现通常不会比成人病例更严重。极少有新生儿和婴儿发生 mpox,因此尚不清楚幼儿(尤其是<6月龄的婴儿)是否会出现更严重的病情。[118]Centers for Disease Control and Prevention. Clinical considerations for mpox in children and adolescents. Sep 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pediatric.html
儿童感染通常是由家庭接触或与受感染动物密切接触导致。[119]Huang YA, Howard-Jones AR, Durrani S, et al. Monkeypox: a clinical update for paediatricians. J Paediatr Child Health. 2022 Sep;58(9):1532-8. https://onlinelibrary.wiley.com/doi/10.1111/jpc.16171 http://www.ncbi.nlm.nih.gov/pubmed/35979896?tool=bestpractice.com 而家庭内儿童接触者中的继发性感染率似乎较低(4.7%)。[120]Wendorf KA, Ng R, Stainken C, et al. Household transmission of mpox to children and adolescents, California, 2022. J Infect Dis. 2023 Oct 13:jiad448. https://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiad448/7311272 http://www.ncbi.nlm.nih.gov/pubmed/37831784?tool=bestpractice.com
孕妇(重症)
孕妇罹患重症的风险可能增加。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 [7]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577 http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com [89]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988. http://apps.who.int/iris/handle/10665/39485 有关妊娠期的数据有限。尚不清楚孕妇是否更易感染,或者疾病在妊娠期是否更为严重。然而,据报道,不良妊娠结局包括自发性妊娠丢失、死产、早产和新生儿感染。可能发生围产期传播。[7]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577 http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com [121]Centers for Disease Control and Prevention. Clinical considerations for mpox in people who are pregnant or breastfeeding. Mar 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html [122]Dashraath P, Nielsen-Saines K, Rimoin A, et al. Monkeypox and pregnancy: virology, clinical presentation, and obstetric management. Am J Obstet Gynecol. 2022 Dec;227(6):849-61. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9534101 http://www.ncbi.nlm.nih.gov/pubmed/35985514?tool=bestpractice.com 妊娠期感染可能导致围产期死亡和垂直传播高风险,具体取决于病毒分支。[123]D'Antonio F, Pagani G, Buca D, et al. Monkeypox infection in pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM. 2022 Sep 9:100747. https://www.ajogmfm.org/article/S2589-9333(22)00178-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36096413?tool=bestpractice.com
在 2022 年全球暴发期间,报告了至少 58 例孕妇感染病例,但无围产期不良结局(包括死产)的报告。[124]Schwartz DA, Pittman PR. Mpox (monkeypox) in pregnancy: viral clade differences and their associations with varying obstetrical and fetal outcomes. Viruses. 2023 Jul 28;15(8):1649. https://www.mdpi.com/1999-4915/15/8/1649 http://www.ncbi.nlm.nih.gov/pubmed/37631992?tool=bestpractice.com
免疫功能低下(重症)
免疫功能低下者罹患重症的风险可能增加。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 [7]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577 http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com [89]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988. http://apps.who.int/iris/handle/10665/39485 免疫功能低下者(即因疾病或免疫抑制剂治疗而免疫功能低下的人群)的数据有限。尽管免疫功能低下者感染和患重症的风险可能更高,但严重结局并不普遍。[33]Centers for Disease Control and Prevention. Clinical considerations for treatment and prophylaxis of mpox infection in people who are immunocompromised. Sep 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/people-with-HIV.html 实体器官移植受者中已有播散性感染的报道。[125]Attieh RM, Brumble L, Elwasila SM, et al. Disseminated monkeypox infection in a kidney transplant recipient: a case report. Transplant Proc. 2023 Apr;55(3):667-71. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10028390 http://www.ncbi.nlm.nih.gov/pubmed/36941151?tool=bestpractice.com [126]Fuller R, Cederroth T, Patel G, et al. First case of rapidly fatal mpox from secondary (household) transmission in a kidney transplant recipient. Am J Transplant. 2023 Jul 28:S1600-6135(23)00594-4. http://www.ncbi.nlm.nih.gov/pubmed/37516244?tool=bestpractice.com
HIV 感染(重症)
没有证据表明 HIV 控制良好者患重症的风险增加。[127]Pilkington V, Quinn K, Campbell L, et al. Clinical Presentation of Monkeypox in People With and Without HIV in the United Kingdom During the 2022 Global Outbreak. AIDS Res Hum Retroviruses. 2023 May 11[Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/37071153?tool=bestpractice.com 然而,HIV 相关性免疫抑制者和病毒未抑制的 HIV 感染者患重症的风险可能增加。目前尚不清楚 HIV 感染状况是否会增加感染风险。[33]Centers for Disease Control and Prevention. Clinical considerations for treatment and prophylaxis of mpox infection in people who are immunocompromised. Sep 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/people-with-HIV.html
有限的数据表明,晚期或未控制的 HIV 感染者患重度或长期疾病的风险更高。一项对尼日利亚病例进行的回顾性分析发现,HIV 感染者的病程更长、病损面积更大、继发细菌性皮肤感染和溃疡的发生率更高。[128]Ogoina D, Iroezindu M, James HI, et al. Clinical course and outcome of human monkeypox in Nigeria. Clin Infect Dis. 2020 Nov 5;71(8):e210-4. https://academic.oup.com/cid/article/71/8/e210/5734993 http://www.ncbi.nlm.nih.gov/pubmed/32052029?tool=bestpractice.com
来自 2022 年全球暴发的数据表明,HIV 感染与疾病严重程度无关。[99]Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox virus infection in humans across 16 countries: April–June 2022. N Engl J Med. 2022 Aug 25;387(8):679-91. https://www.nejm.org/doi/full/10.1056/NEJMoa2207323 http://www.ncbi.nlm.nih.gov/pubmed/35866746?tool=bestpractice.com [129]Kowalski J, Cielniak I, Garbacz-Łagożna E, et al. Comparison of clinical course of mpox among HIV-negative and HIV-positive patients: a 2022 cohort of hospitalized patients in Central Europe. J Med Virol. 2023 Oct;95(10):e29172. http://www.ncbi.nlm.nih.gov/pubmed/37861345?tool=bestpractice.com 然而,来自美国的数据表明,与非 HIV 感染者相比,HIV 感染者的住院率可能更高,尤其是 CD4 计数较低或病毒未得到抑制者。[130]Curran KG, Eberly K, Russell OO, et al. HIV and sexually transmitted infections among persons with monkeypox: eight US jurisdictions, May 17 - July 22, 2022. MMWR Morb Mortal Wkly Rep. 2022 Sep 9;71(36):1141-7. https://www.cdc.gov/mmwr/volumes/71/wr/mm7136a1.htm http://www.ncbi.nlm.nih.gov/pubmed/36074735?tool=bestpractice.com [131]Chastain DB, Motoa G, Ortiz-Martínez Y, et al. Characteristics and clinical manifestations of monkeypox among people with and without HIV in the United States: a retrospective cohort. AIDS. 2023 Mar 15;37(4):611-6. http://www.ncbi.nlm.nih.gov/pubmed/36729995?tool=bestpractice.com
晚期 HIV 感染或 AIDS 患者发生严重并发症、入住重症监护室和死亡的风险增加。[132]Miller MJ, Cash-Goldwasser S, Marx GE, et al. Severe monkeypox in hospitalized patients: United States, August 10 - October 10, 2022. MMWR Morb Mortal Wkly Rep. 2022 Nov 4;71(44):1412-7. https://www.cdc.gov/mmwr/volumes/71/wr/mm7144e1.htm http://www.ncbi.nlm.nih.gov/pubmed/36327164?tool=bestpractice.com [133]Triana-González S, Román-López C, Mauss S, et al. Risk factors for mortality and clinical presentation of monkeypox. AIDS. 2023 Nov 1;37(13):1979-85. http://www.ncbi.nlm.nih.gov/pubmed/37294338?tool=bestpractice.com 与 CD4 计数<300 个细胞/μL 的患者相比,CD4 计数<100 个细胞/μL 的患者更常出现严重并发症,包括坏死性皮损、肺功能障碍、继发性感染和脓毒症。所有死亡都发生在 CD4 计数<200 个细胞/μL 的患者中,且其中大多数是 HIV 病毒载量高的患者。[134]Mitjà O, Alemany A, Marks M, et al. Mpox in people with advanced HIV infection: a global case series. Lancet. 2023 Mar 18;401(10380):939-49. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00273-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36828001?tool=bestpractice.com
不认为正在接受抗逆转录病毒治疗且病毒载量得到抑制的 HIV 携带者属于免疫力低下人群。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 达到病毒载量抑制/不可检出可防止更严重的病程。[135]Bragazzi NL, Kong JD, Mahroum N, et al. Epidemiological trends and clinical features of the ongoing monkeypox epidemic: a preliminary pooled data analysis and literature review. J Med Virol. 2023 Jan;95(1):e27931. http://www.ncbi.nlm.nih.gov/pubmed/35692117?tool=bestpractice.com
观察性证据表明,在随后感染 HIV 的人群中,对儿童期天花疫苗接种的免疫应答下降更快,并且在接受抗逆转录病毒治疗的患者中,抗原特异性 CD4+ T 细胞对疫苗接种或 HIV 感染前感染的记忆在免疫重建后没有恢复。[136]Thomas A, Hammarlund E, Gao L, et al. Loss of preexisting immunological memory among human immunodeficiency virus-infected women despite immune reconstitution with antiretroviral therapy. J Infect Dis. 2020 Jun 29;222(2):243-51. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323495 http://www.ncbi.nlm.nih.gov/pubmed/31867597?tool=bestpractice.com
急性或慢性皮肤病(重症)
有影响皮肤完整性的疾病(如湿疹、烧伤、脓疱病、带状疱疹、单纯疱疹感染、严重痤疮、严重尿布疹、银屑病、毛囊角化症)病史或存在这些情况者患重症或并发症(如继发性细菌感染)的风险可能增加。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 [137]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html 特应性皮炎患者可能更容易发生感染,并可能出现猴痘湿疹(eczema monkeypoxicum)。[138]Xia J, Huang CL, Chu P, et al. Eczema monkeypoxicum: report of monkeypox transmission in a patient with atopic dermatitis. JAAD Case Rep. 2022 Nov;29:95-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9534102 http://www.ncbi.nlm.nih.gov/pubmed/36212897?tool=bestpractice.com [139]Napoli E, Frizzell M, Gravell C, et al. Eczema monkeypoxicum in a female patient with atopic dermatitis. Open Forum Infect Dis. 2023 Mar;10(3):ofad072. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10043130 http://www.ncbi.nlm.nih.gov/pubmed/36998632?tool=bestpractice.com
弱
性传播感染
在 2022 年全球暴发中,有 29% 的患者报告了伴随性传播感染(sexually transmitted infection, STI)。[99]Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox virus infection in humans across 16 countries: April–June 2022. N Engl J Med. 2022 Aug 25;387(8):679-91. https://www.nejm.org/doi/full/10.1056/NEJMoa2207323 http://www.ncbi.nlm.nih.gov/pubmed/35866746?tool=bestpractice.com 然而,在此阶段尚不清楚 STI 是否有助于传播或改变临床表现。[140]Ramoni S, Maronese CA, Morini N, et al. Syphilis and monkeypox co-infection: coincidence, synergy or asymptomatic carriage? Travel Med Infect Dis. 2022 Sep 5;50:102447. https://www.sciencedirect.com/science/article/pii/S1477893922001934 http://www.ncbi.nlm.nih.gov/pubmed/36067937?tool=bestpractice.com
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