猴痘（mpox）

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. June 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 对所有符合疑似、可能或拟诊病例定义者均应予以检测。[166]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1 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），鉴于其准确性和敏感性，为首选实验室检查。NAAT 可通用于正痘病毒 检测，亦可特定用于猴痘病毒检测（倾向于后者）。[166]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1 [167]UK Health Security Agency. Monkeypox: diagnostic testing. November 2022 [internet publication]. https://www.gov.uk/guidance/monkeypox-diagnostic-testing [168]Centers for Disease Control and Prevention. Guidelines for collecting and handling specimens for monkeypox testing. September 2022 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/prep-collection-specimens.html [169]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 测序对于确定病毒进化枝和理解其流行病学十分具有帮助。

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 [男男性行为] 人群、不符合猴痘的征象/症状）的单一检测结果进行解读时，需要保持谨慎。[171]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。[172]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。[171]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 [173]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。[166]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1 [168]Centers for Disease Control and Prevention. Guidelines for collecting and handling specimens for monkeypox testing. September 2022 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/prep-collection-specimens.html 皮损拭子是利用 PCR 检测猴痘病毒 DNA 最有效的手段。[174]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 [175]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，在拭子采样前，没有必要（或不建议）对病灶进行抽吸或去顶。选取样本类型可能因皮疹分期而有所不同。参考实验室还可能要求采集口咽拭子、加入乙二胺四乙酸（ethylenediamine tetra-acetic acid, EDTA）的血液或尿液。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，但没有皮疹或病灶可供采样。[167]UK Health Security Agency. Monkeypox: diagnostic testing. November 2022 [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。[146]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 [176]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  支持使用除直接从皮损处所采集拭子样本外的其他样本类型（例如血液、唾液）进行检测的数据有限。检测非取自皮损的样本可能导致假阳性结果。[177]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 [178]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 [179]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. 2022 Oct 2 [Epub ahead of print]. 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，将猴痘可能性通知实验室。关于实验室安全处理此类标本，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。

UKHSA: monkeypox - diagnostic testing Opens in new window

CDC: guidelines for collecting and handling specimens for monkeypox testing Opens in new window

检查

对所有疑似感染患者都应进行该项检查。

小型研究发现白细胞增多常见，淋巴细胞增多和血小板减少在患病期间见于超过 1/3 的患者。[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

白细胞增多和血小板减少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

检查

对所有疑似感染患者都应进行该项检查。

小规模研究发现，患病期间尿素过低较为常见。[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

尿素过低可能是重症或复杂性疾病的信号。[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

检查

对所有疑似感染患者都应进行该项检查。

小型研究显示，转氨酶升高和低白蛋白血症在患病期间常见。[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 [27]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 转氨酶升高和低白蛋白血症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 在猴痘和肝炎同时感染的患者中曾报告重度肝炎。[187]Oprea C, Ionuț Popa, Ianache I, et al. Monkeypox, severe hepatitis A, and syphilis in an HIV returning traveler from Spain to Romania. Travel Med Infect Dis. 2022 Sep 8:102455. https://www.sciencedirect.com/science/article/pii/S1477893922002010 http://www.ncbi.nlm.nih.gov/pubmed/36089283?tool=bestpractice.com

检查

检查所有有性行为的成人及青少年有无 HIV 感染和其他 STI。[101]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

猴痘的临床特征易与 STI 相混淆。因此，对于出现生殖器或肛周溃疡的患者，全面评估是否存在 STI 很重要。可能存在混合感染，而存在 STI 并不能排除猴痘。[133]Centers for Disease Control and Prevention. Monkeypox: clinician FAQs. October 2022 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/faq.html

检查

对于重度肛门直肠直肠炎患者，考虑腹部/盆腔 CT 扫描。

造影剂增强 CT 可发现周向肛门直肠壁增厚，伴壁内溃疡所致的广泛离散的非增强低衰减区。其他发现可能包括直肠周围脂肪浸润、骶前水肿、腹水和腹股沟小淋巴结数量增加。[180]Messina MD, Wolf EL, Kanmaniraja D, et al. Imaging features of anorectal proctitis in monkeypox infection. Clin Imaging. 2022 Dec;92:109-11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9583688 http://www.ncbi.nlm.nih.gov/pubmed/36302321?tool=bestpractice.com

检查

世界卫生组织（World Health Organization , WHO）目前不建议将血清学检测用于诊断。如果检测样本产生不确定性结果，则血清学检测（至少间隔 21 天，收集成对血清样本，第一次采血在患病第一周进行）能帮助诊断。近期免疫接种可能对血清学检测产生干扰。[166]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1 不过，WHO 和疾病预防控制中心在其病例定义中，将血清学检测作为一种选择。[79]World Health Organization. Surveillance, case investigation and contact tracing for monkeypox: interim guidance, 25 August 2022. August 2022 [internet publication]. https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2022.3 [137]Centers for Disease Control and Prevention. Case definitions for use in the 2022 monkeypox response. July 2022 [internet publication]. https://www.cdc.gov/poxvirus/monkeypox/clinicians/case-definition.html 参阅诊断标准章节。

检查

如果怀疑皮肤病灶存在细菌超级感染，或怀疑体弱患者存在细菌感染，则应在患者处于隔离状态时，且在给予抗生素治疗前，进行检查。

检查

对于所有疑似感染患者，如果具有疟疾流行地区近期旅行史，则应进行该检查。

对于任何到过疟疾流行地区的发热患者，尤其是在发热之前 3 周内去过疟疾流行地区的患者，始终应排除疟疾混合感染的可能性。

抗原检测给实验室工作人员带来的感染隐患小于制备厚血膜涂片和薄血膜涂片带来的隐患。必须首先将猴痘风险告知实验室，按照当地政策组织标本的安全运输。