Monkeypox‐Associated Central Nervous System Disease: A Case Series and Review

Author:

Money Kelli M.1ORCID,Barnett T. Allen2,Rapaka Samuel3,Osborn Rebecca4,Kitani Takashi5,Fuguet Daniel6,Amjad Faria5,Clark Jeffrey R.2ORCID,Chakravarty Debanjana78,Copeland Matthew J.3,Honce Justin M.6,Kumar Princy N.3,Kumar Rebecca N.3ORCID,Mousa‐Ibrahim Fady2,Sirdar Bilaal5ORCID,Sobota Rafal2,Tang Mengxuan2,Bolon Maureen K.4,Russell Eric J.29,Wilson Michael78ORCID,Tornatore Carlo5,Batra Ayush210ORCID,Tyler Kenneth L.111,Pastula Daniel M.112ORCID

Affiliation:

1. Neuroinfectious Diseases Group, Departments of Neurology and Medicine (Infectious Diseases) University of Colorado School of Medicine Aurora Colorado USA

2. Ken & Ruth Davee Department of Neurology Northwestern University Feinberg School of Medicine Chicago Illinois USA

3. Department of Infectious Diseases Georgetown University Medical Center Washington District of Columbia USA

4. Division of Infectious Diseases Northwestern University Feinberg School of Medicine Chicago Illinois USA

5. Department of Neurology Georgetown University Medical Center Washington District of Columbia USA

6. Department of Radiology University of Colorado School of Medicine Aurora Colorado USA

7. Weill Institute for Neurosciences University of California, San Francisco San Francisco California USA

8. Department of Neurology University of California, San Francisco San Francisco California USA

9. Department of Radiology Northwestern University Feinberg School of Medicine Chicago Illinois USA

10. Department of Pathology Northwestern University Feinberg School of Medicine Chicago Illinois USA

11. Department of Immunology and Microbiology University of Colorado School of Medicine Aurora Colorado USA

12. Department of Epidemiology Colorado School of Public Health Aurora Colorado USA

Abstract

ObjectiveMonkeypox virus (MPXV) disease has been declared a public health emergency by the World Health Organization, creating an urgent need for neurologists to be able to recognize, diagnosis, and treat MPXV‐associated neurologic disease.MethodsThree cases of MPXV‐associated central nervous system (CNS) disease occurring during the 2022 outbreak, and their associated imaging findings are presented, with 2 cases previously published in a limited capacity in a public health bulletin.ResultsThree previously healthy immunocompetent gay men in their 30s developed a febrile illness followed by progressive neurologic symptoms with presence of a vesiculopustular rash. MPXV nucleic acid was detected by polymerase chain reaction (PCR) from skin lesions of 2 patients, with the third patient having indeterminate testing but an epidemiologic link to a confirmed MPXV disease case. Cerebrospinal fluid demonstrated a lymphocytic pleocytosis, elevated protein, and negative MPXV‐specific PCR. In 2 patients, magnetic resonance imaging of the brain and spine demonstrated partially enhancing, longitudinally extensive central spinal cord lesions with multifocal subcortical, basal ganglia, thalamic, cerebellar, and/or brainstem lesions. The third patient had thalamic and basal ganglia lesions. All patients received 14 days of tecovirimat, and 2 patients also received multiple forms of immunotherapy, including intravenous immunoglobulin, pulsed high‐dose steroids, plasmapheresis, and/or rituximab. Good neurologic recovery was observed in all cases.InterpretationMPXV can be associated with CNS disease. It is unclear whether this is from a parainfectious immune‐mediated injury or direct CNS viral invasion. ANN NEUROL 2023;93:893–905

Publisher

Wiley

Subject

Neurology (clinical),Neurology

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