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Paediatric monkeypox patient with unknown source of infection, the Netherlands, June 2022 - ECDC

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  • Paediatric monkeypox patient with unknown source of infection, the Netherlands, June 2022 - ECDC


    Since May 2022, an international monkeypox (MPX) outbreak has been ongoing in more than 50 countries. While most cases are men who have sex with men, transmission is not restricted to this population. In this report, we describe the case of a male child younger than 10 years with MPX in the Netherlands. Despite thorough source tracing, a likely source of infection has not been identified. No secondary cases were identified in close contacts.

    A Marceline Tutu van Furth1,2,* , Martijn van der Kuip1,2,* , Anne L van Els1,2 , Lydia CR Fievez3 , Gini GC van Rijckevorsel3,4 , Anton van den Ouden5 , Marcel Jonges6 , Matthijs RA Welkers6,7

    While repeated community outbreaks of monkeypox (MPX) have been reported in African countries and the United States, these were mainly caused by spillover events from animals to humans [1,2]. Many of these cases also involved children, with a case fatality rate (CFR) between 3.6% and 10.6% depending upon the MPX clade [3,4]. The current global outbreak of MPX does not appear to have a clear link to Africa and distinguishes itself from previous reported outbreaks in that there is more sustained transmission within the community of men who have sex with men (MSM) [5]. The infection of children is very rare and warrants further investigation.

    Clinical case description

    At the end of June 2022, a male child younger than 10 years without relevant medical history presented at a paediatric emergency room (ER) in Amsterdam, the Netherlands. He was vaccinated according to the Dutch national vaccination programme and had chicken pox when he was 5 years-old. Three weeks before his visit, he experienced a sore throat without fever that spontaneously resolved on the next day. A day later, he travelled to Turkey for a 1-week holiday. After his return, he noticed two small round skin lesions on his left lower jaw and cheek (Figure 1A). The general practitioner (GP) started with antifungal cream under the suspicion of a mild dermatomycosis. In the following days, more lesions appeared in the child’s face. The GP was again consulted and antibiotic cream was started for suspected impetigo vulgaris. When ca 20 solitary lesions appeared on other body parts (Figure 1B-D) the child was referred to our hospital under the clinical suspicion of MPX. On physical examination, we observed an alert child in overall good health with stable vital parameters and without fever. There were no enlarged lymph nodes in the neck, armpits or groin region. The liver or spleen did not seem enlarged upon abdominal palpation. On the skin, we observed a centrifugal distribution of 20 solitary, sharply demarcated, red-brown vesicles (left ear, left lower jaw, both forearms, both thighs and on the back). No lesions in the oral cavity or genital region were seen.

    Laboratory analysis showed a normal erythrocyte sedimentation rate (12 mm/h; reference value: 0–13 mm/h) and low C-reactive protein (1,9 mg/L; reference value: 0–5 mg/L). Haemoglobin, thrombocytes and leucocyte counts were also in the normal range. Unexpectedly, the child had an immunoglobulin A (IgA) deficiency (0.45 g/L; reference value: 0.53–2.04 g/L).

    As the major transmission route in the current MPX outbreak is related to sexual activity [5], we ruled out the possibility of sexual abuse by taking careful history and tested for syphilis (negative serology), gonorrhoea (negative peri-anal swab PCR), chlamydia (negative peri-anal swab PCR), HIV infection (negative P24 antigen/antibody test on serum) and hepatitis B and C (negative HBsAg, negative anti-HB core, positive anti-HbS, negative anti-HCV). A PCR for varicella zoster virus on the vesicle fluid was also negative.

    ... We describe a paediatric case of MPX in the Netherlands. We were not able to identify any possible source of the infection. Whole genome sequencing positioned the patient’s sequence within the clade 3 lineage B.1, but did not directly link to any other strains from the Amsterdam region.