Many patients experience persistent pain after having Clade IIb mpox

In a rapid communication published in the journal Eurosurveillance, researchers presented the interim results of a medium-term follow-up [three weeks to twenty weeks following MPOX virus infection follow-up study comprising patients attending sexual health clinics in Belgium.

Rapid communication: Persistent morbidity in Clade IIb mpox patients: interim results of a long-term follow-up study, Belgium, June to November 2022. Image Credit:  Dotted Yeti / Shutterstock

Background

In the global 2022 MPOX outbreak, most patients presented with non-specific prodromal symptoms and lesions localized to the mucosa and skin, especially in the anogenital region. The majority of the infections were of mild intensity, not requiring hospitalization, and very few deaths were reported in the European Union region through January 2023.

However, acute MPOX complications such as bacterial superinfections, penile edema, proctitis, paraphimosis, and urinary retention were documented, and the clinical presentation was especially severe among immunosuppressed individuals. Data on the long-term consequences of MPOX are limited.

About the rapid communication

In the present rapid communication, researchers reported on MPOX-associated morbidities, analyzing initial sexual health clinic visit data of an ongoing study conducted on MPOX patients between June and November 2022.

Among >300 individuals diagnosed with MPOX between May and October 2022, 169 patients were interviewed during the initial presentation of MPOX and showed willingness for follow-up assessments during the post-convalescent periods at 3.0 to 6.0 weeks, 6 months, and 1 year following the onset of MPOX symptoms. Data were obtained via standardized questionnaires filled out by MPOX patients and physicians at follow-up.

Individuals with medium-term MPOX-associated morbidities were those reporting persistent anorectal or genital symptoms sequelae, worsening of mental well-being, fatigue, and fitness loss. Additionally, MPOX-associated mental health outcomes, probably after isolation requirements and associated stigmatization, were assessed. Logistic regression modeling was performed, and the odds ratios (OR) were calculated. Depression and anxiety were evaluated using the depression anxiety stress scale-21 (DASS-21).

Results

Out of 169 individuals, 56% (n=95) attended sexual health clinics at the initial follow-up; however, only 64% (n=61) of them visited the clinic during the foreseen period, and the remaining 34 individuals returned for their initial visit following seven weeks to 20 weeks. On the whole, 42 out of 61 individuals in the early (3 to 6 weeks) period and 22 out of 34 individuals in the late (7 to 20 weeks) period documented medium-term MPOX-associated morbidities.

Out of 61 early-group MPOX patients, 33 individuals developed proctitis or perianal lesions in the acute phase of MPOX, among whom 17 individuals reported residual pain in the anal region during follow-up. Among the 33 patients, 10 and 12 reported pain during rest and defecation, respectively. Among early group patients, 32 developed genital mucosal lesions in the acute MPOX phase, among whom 12 documented genital signs and symptom persistence after 3 to 6 weeks; seven and eight individuals had scars and pain (during rest) in the genital region, respectively. 

Of 11 individuals resuming sexual activities, four individuals documented pain in the anal region during receptive-type of anal sexual intercourse, and four other individuals experienced pain in the genital region during penetrative sexual intercourse. Nine early group individuals documented moderate-severe intensity fitness loss. Of 36 individuals questioned related to their mental well-being and fatigue, 14 and 10 individuals documented new-onset or worsening fatigue mental illness, respectively.

Three individuals experienced moderate-severe levels of anxiety, three individuals experienced depression of similar intensity, and elevated stress levels were reported for two individuals. Among late group individuals, 14 presented with proctitis or perianal lesions in the acute MPOX period, among which eight individuals documented residual anorectal symptoms and signs. The clinical presentation included pain in the anal region during rest or pain during defecation, scarring, and pain while engaging in receptive-type sexual intercourse among three, two, three, and three individuals, respectively.

At diagnosis of MPOX, 13 MPOX late-group patients presented with genital lesions, among which six patients reported residual genital issues during follow-up, including genital scars (four patients), penile insensitivity (one patient), pain during penile erection (one patient) and pain in the genital region during rest (one patient). Two patients in the late group documented moderate-severe fitness loss. Out of 19 individuals questioned concerning their mental health and fatigue status, one and five individuals reported new-onset or worsening mental health issues and fatigue, respectively. Persistent anorectal pain seemed to be related to severe-intensity pain in the acute phase of MPOX.

Among the study participants, medium-term MPOX-associated morbidities’ presence showed a negative association with age (OR 1.0), with a four-fold more significant risk of MPOX-associated morbidity among individuals aged ≤47.0 years than individuals of older age (OR 4.4). In addition, younger age increased the risk of developing fatigue by 10-fold (OR 10). Scarring in the genital region seemed to increase the risk of persistent pain in the genital region during the follow-up periods (OR 6.5).

Overall, the study findings highlighted the prevalence of medium-term MPOX-associated morbidities that could reduce the quality of life. Importantly, healthcare professionals must be aware of the morbidities and altered mental well-being status that might persist among individuals infected with clade IIb MPOX.

Written by

Pooja Toshniwal Paharia

Dr. based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.