检查
对于疑似感染的患者,应尽快实施检测。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
对所有符合疑似或拟诊病例定义者予以检测。[214]World Health Organization. Diagnostic testing for the monkeypox virus (MPXV): interim guidance. May 2024 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Laboratory-2024.1
应基于临床和流行病学因素(与感染可能性评估相关),确定是否检测在患者检测结果出来之前,仍应隔离患者。
地区公共卫生实验室可进行检测。目前尚无市售试剂盒。
使用实时 PCR 或传统 PCR 的核酸扩增检测(nucleic acid amplification testing, NAAT)具有较高的准确度和敏感度,是首选实验室检查。这一检查可单用或联合测序用于病毒分支测定。NAAT 可通用于正痘病毒检测,也可专门用于猴痘病毒检测(首选检测)。若正痘病毒 PCR 检测结果呈阳性,应进行猴痘病毒 PCR 检测和/或测序以确诊。分支特定 NAAT 未能检测到猴痘时,随后可能使用测序法来确定病毒分支及基因特征。[214]World Health Organization. Diagnostic testing for the monkeypox virus (MPXV): interim guidance. May 2024 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Laboratory-2024.1
[215]UK Health Security Agency. Mpox (monkeypox): diagnostic testing. Jan 2024 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
[216]Centers for Disease Control and Prevention. Guidelines for collecting and handling specimens for mpox testing. Apr 2024 [internet publication].
https://www.cdc.gov/poxvirus/mpox/clinicians/prep-collection-specimens.html
[217]Altindis M, Puca E, Shapo L. Diagnosis of monkeypox virus: an overview. Travel Med Infect Dis. 2022 Sep 13;50:102459.
https://www.sciencedirect.com/science/article/pii/S1477893922002058
http://www.ncbi.nlm.nih.gov/pubmed/36109000?tool=bestpractice.com
测序有助于确定病毒分支和理解其流行病学。在 2023 年发现性传播 Ⅰ 分支感染聚集病例(由新发现的 Ⅰb 分支所致)后,建议对所有猴痘病毒检测阳性的患者均进行分支检测。[215]UK Health Security Agency. Mpox (monkeypox): diagnostic testing. Jan 2024 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
[222]McQuiston JH, Luce R, Kazadi DM, et al. U.S. preparedness and response to increasing clade I mpox cases in the Democratic Republic of the Congo - United States, 2024. MMWR Morb Mortal Wkly Rep. 2024 May 16;73(19):435-40.
https://www.cdc.gov/mmwr/volumes/73/wr/mm7319a3.htm
http://www.ncbi.nlm.nih.gov/pubmed/38753567?tool=bestpractice.com
由于存在假阳性结果风险,对感染验前概率较低患者(例如缺乏流行病学关联、非 MSM [men who have sex with men, 男男性行为者] 人群、不符合 mpox 的体征/症状)的单次检测结果进行解读时,需要保持谨慎。[219]Minhaj FS, Petras JK, Brown JA, et al. Orthopoxvirus testing challenges for persons in populations at low risk or without known epidemiologic link to monkeypox: United States, 2022. MMWR Morb Mortal Wkly Rep. 2022 Sep 9;71(36):1155-8.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7136e1.htm
http://www.ncbi.nlm.nih.gov/pubmed/36074752?tool=bestpractice.com
无流行病学标准或明确危险因素时,正痘病毒或猴痘病毒 DNA 检测呈阳性者应进行重复检测和/或确认性检测加以核实,并对皮疹的其他可能性原因加以考虑。[220]Centers for Disease Control and Prevention. Update for clinicians on testing and treatment for monkeypox. July 2022 [internet publication].
https://emergency.cdc.gov/han/2022/han00471.asp
建议对实时(real-time, RT)-PCR 循环阈值较高(即 ≥34)的患者进行重复检测(重新提取和检测标本),因为这表明病毒 DNA 水平较低,标本感染性较差,或不具感染性。[219]Minhaj FS, Petras JK, Brown JA, et al. Orthopoxvirus testing challenges for persons in populations at low risk or without known epidemiologic link to monkeypox: United States, 2022. MMWR Morb Mortal Wkly Rep. 2022 Sep 9;71(36):1155-8.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7136e1.htm
http://www.ncbi.nlm.nih.gov/pubmed/36074752?tool=bestpractice.com
[221]Paran N, Yahalom-Ronen Y, Shifman O, et al. Monkeypox DNA levels correlate with virus infectivity in clinical samples, Israel, 2022. Euro Surveill. 2022 Sep;27(35).
https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.35.2200636
http://www.ncbi.nlm.nih.gov/pubmed/36052723?tool=bestpractice.com
推荐样本类型为皮损组织,包括皮损渗出物拭子、一个以上皮损的病灶组织,或皮损结痂。[214]World Health Organization. Diagnostic testing for the monkeypox virus (MPXV): interim guidance. May 2024 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Laboratory-2024.1
[215]UK Health Security Agency. Mpox (monkeypox): diagnostic testing. Jan 2024 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
[216]Centers for Disease Control and Prevention. Guidelines for collecting and handling specimens for mpox testing. Apr 2024 [internet publication].
https://www.cdc.gov/poxvirus/mpox/clinicians/prep-collection-specimens.html
皮损拭子是利用 PCR 检测猴痘病毒 DNA 最有效的方法。[223]Martins-Filho PR, Tanajura DM, Alves Dos Santos C. Polymerase chain reaction positivity and cycle threshold values in biological samples from patients with monkeypox: a meta-analysis. Travel Med Infect Dis. 2022 Sep 7;50:102448.
https://www.sciencedirect.com/science/article/pii/S1477893922001946
http://www.ncbi.nlm.nih.gov/pubmed/36087645?tool=bestpractice.com
[224]Hasso M, Perusini S, Eshaghi A, et al. Monkeypox virus detection in different clinical specimen types. Emerg Infect Dis. 2022 Oct 12;28(12).
https://wwwnc.cdc.gov/eid/article/28/12/22-1160_article
http://www.ncbi.nlm.nih.gov/pubmed/36223653?tool=bestpractice.com
由于存在锐器损伤风险,不需要(或不建议)在拭子采样前对病损进行抽吸或去顶。样本类型的选取可能因皮疹所处分期不同而异。参考实验室还可能要求采集口咽拭子、肛门直肠拭子、加入乙二胺四乙酸(ethylenediamine tetra-acetic acid, EDTA)的血液样本,以及尿液样本。对于疑似或确诊病例的接触者,无肉眼可见皮损或黏膜病损时,可采集其他类型的样本(例如口咽拭子样本)。但这对处于症状前期的病例可能缺乏敏感性,因此在皮疹或黏膜病变出现后应再次取样进行检查。[214]World Health Organization. Diagnostic testing for the monkeypox virus (MPXV): interim guidance. May 2024 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Laboratory-2024.1
建议对确诊或高度拟诊病例的高危接触者进行口咽拭子采样,这些接触者已出现全身症状,但没有皮疹或病损可供采样。如果有咽部病损,还应采集咽拭子。[215]UK Health Security Agency. Mpox (monkeypox): diagnostic testing. Jan 2024 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
然而,病变拭子的病毒载量高于咽样本,并且已知口咽拭子是初步诊断不可靠的独立样本类型。[191]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
[225]Nörz D, Brehm TT, Tang HT, et al. Clinical characteristics and comparison of longitudinal qPCR results from different specimen types in a cohort of ambulatory and hospitalized patients infected with monkeypox virus. J Clin Virol. 2022 Aug 11;155:105254.
https://www.sciencedirect.com/science/article/pii/S138665322200186X
http://www.ncbi.nlm.nih.gov/pubmed/36057206?tool=bestpractice.com
除直接从皮损处采集拭子样本外,支持使用其他类型样本(例如血液、唾液)进行检测的数据有限。检测非皮损处的样本可能导致假阳性结果。[226]US Food and Drug Administration. For monkeypox testing, use lesion swab samples to avoid false results: FDA safety communication. July 2022 [internet publication].
https://www.fda.gov/medical-devices/safety-communications/monkeypox-testing-use-lesion-swab-samples-avoid-false-results-fda-safety-communication
[227]Veintimilla C, Catalán P, Alonso R, et al. The relevance of multiple clinical specimens in the diagnosis of monkeypox virus, Spain, June 2022. Euro Surveill. 2022 Aug;27(33).
https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.33.2200598
http://www.ncbi.nlm.nih.gov/pubmed/35983771?tool=bestpractice.com
[228]Allan-Blitz LT, Carragher K, Sukhija-Cohen A, et al. Laboratory validation and clinical performance of a saliva-based test for monkeypox virus. J Med Virol. 2023 Jan;95(1):e28191.
https://onlinelibrary.wiley.com/doi/10.1002/jmv.28191
http://www.ncbi.nlm.nih.gov/pubmed/36183189?tool=bestpractice.com
根据地区或国家操作常规,进行样本采集、标记、包装和送检。样本送检之前,通知实验室可能为 mpox。关于在实验室安全处理此类样本,以及将此类病毒学样本进一步转送至参考实验室,已有当地规程可供参考。将用于检测其他感染的样本单独包装。
参考实验室采用 PCR 检测痘病毒 DNA 时,应自动检测样本是否有水痘带状疱疹病毒。混合感染时,水痘带状疱疹病毒 DNA 可能呈阳性。
一些国家/地区可提供即时检测。
UKHSA: mpox (monkeypox) - diagnostic testing
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CDC: guidelines for collecting and handling specimens for mpox testing
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