[Affenpocken: orale Manifestation als diagnostischer Indikator]
Raquel D’Aquino Garcia Caminha 1Gabriel de Toledo Telles-Araujo 2
Gabriel Araujo-Silva 3
Liliane Lins-Kusterer 2
Paulo Sérgio da Silva Santos 1
1 Department of Surgery, Stomatology, Pathology and Radiology, Bauru Dental School, University of São Paulo, Bauru, Brazil
2 School of Medicine, Federal University of Bahia, Salvador, Brazil
3 Piracicaba Dental School, University of Campinas, Piracicaba, Brazil
Zusammenfassung
Läsionen an der Mundschleimhaut werden bei etwa 70% der infizierten Patienten beobachtet und als erstes klinisches Anzeichen der Krankheit angegeben. Sie äußern sich auch als Makula, Papeln, Bläschen oder Blasen, die hochgradig ansteckend sind und auf die Läsionen im Gesicht und an den Extremitäten folgen. Diese Läsionen weisen klinische Aspekte auf, die denen von rezidivierendem Herpes simplex, Herpes zoster und sekundärer Syphilis ähneln, weshalb Affenpocken zu den Differentialdiagnosen gehören sollten.
Als Hilfestellung für die klinische Diagnose wird der klinische Verlauf nach oraler Erstmanifestation dargestellt.
Schlüsselwörter
Affenpocken, orale Manifestation, diagnostischer Indikator
Introduction
Monkeypox (MP) is a disease caused by the Monkeypox DNA virus (genus: Orthopoxvirus, family: Poxviridae), a zoonotic pathogen, which is spreading rapidly worldwide [1], [2]. Transmission of MP occurs through direct contact with saliva and respiratory secretions or from virus-infected lesions, through contact on contaminated surfaces, clothing, and objects, and through sexual intercourse [3], [4], [5], [6]. The presence of the virus is documented in semen [7], [8], [9], saliva [7], [9], nasopharyngeal swabs [7], [9], [10], urine [9], blood [7], [8], [9], [10], urine [7], [9], faeces [7], [9], rectal swab [9], skin lesions [8], [9] as well as in oral, pharyngeal and rectal lesions [9].
To date, the most affected population is homosexual patients, mainly males [11], aged between 21 and 40 years [2] and who have not been vaccinated against smallpox [1], [12], [13]. Penetration of the virus may occur via the oropharynx, nasopharynx, and/or skin and then a period of inoculation will occur with subsequent spread of the virus to the lymph nodes and an incubation period of approximately ranging from 7 to 21 days [14].
Clinically, the first signs and symptoms of the disease may appear from the 1st to the 5th day after contamination and manifest themselves through lymphadenopathies (prevalent characteristic), fever, fatigue, headache, and myalgias [15]. After the disappearance of fever, already in the second phase, the patient evolves with numerous rashes on the skin and mucous membranes such as the buccal, genital, cornea, and conjunctiva, with specific sequential stages of macules, papules, vesicles, pustules, crusts, in a typically centripetal manner and that after a few days or weeks heal, leaving the skin and mucosa integral [16], [17], [18], [19], [20]. The literature reports that some cases may also evolve with anal lesions, rectal pain, and penile edema [21], [22].
Oral manifestation of monkeypox
Lesions affecting the oral mucosa have been observed in approximately 70% of infected patients [23] and are reported as the first clinical sign of the disease, also manifesting as macules, papules, vesicles, or blisters, which are highly contagious and are followed by the appearance of lesions on the face and extremities of the body. These lesions have clinical aspects similar to recurrent herpes, herpes zoster, and secondary syphilis and for this reason, MP should be part of the differential diagnoses [24]. In Figure 1 [Fig. 1] a typical clinical course is shown.
Figure 1: Clinical course of oral manifestation of monkeypox (A) Initial oral manifestation with the presence of a papule, (B) After 7 days a larger lesion with scaling and crusting, (C) After 12 days with an ulcer affecting the lip and lower lip mucosa, (D) After 15 days an ulcer on the lower lip with regression in size and the healing process.
The oral lesions of MP present painful symptoms and interfere with feeding, generating a picture of dysphagia/odynophagia, dehydration, and malnutrition, worsening the systemic picture and quality of life [24]. It is noteworthy that oral lesions, regardless of the stage, are contaminated by the virus which consequently enables its spread [21].
Discussion
The oral cavity may be one of the initial sites of the MP lesions, making it essential for health professionals to be informed about these signs and symptoms, which will allow early diagnosis, favoring the prognosis of the patient, besides minimizing infection to other people and the professional himself during clinical care [23]. The secretion from oral lesions can be collected with a swab to identify the DNA of the virus [25] and analyzed through the Polymerase Chain Reaction test for the diagnosis of MP, which is considered the gold standard for this diagnosis [23].
The clinical management of oral lesions of MP may include chemical control through mouthrinses with antimicrobials that will decrease the viral load in the oral cavity, such as 0.12% chlorhexidine without alcohol [26] and mechanical control through patient instruction on the best technique to perform oral hygiene, application of topical or systemic (acyclovir, fanciclovir, penciclovir, cidofovir) antivirals to the lesions [27]. In addition, it is also possible to associate the topical use of benzydamine hydrochloride, which will promote pain control through its anti-inflammatory, analgesic, and anesthetic action, providing greater comfort for the patient to eat properly [28], [29]. The use of low-power lasers presents great results to accelerate injury repair, analgesia, and anti-inflammatory effect, which may also be associated with photodynamic therapy to help reduce the viral load [30]. Laser therapy can also be applied in the management of MP, if its application is feasible, given the limited access to these patients due to the risk of spreading the disease. There are no studies in the literature that use these treatment modalities specifically for cases of MP, but there is scientific evidence of effective results in similar clinical situations, in the treatment of viral lesions, as mentioned above.
The biosafety measures widely discussed during the Covid-19 pandemic [31], should be applied in suspected and/or confirmed cases of MP, such as a thorough anamnesis, use of N-95 or PFF-2 mask, face shield, disposable apron, goggles, abundant hand washing before and aftercare, in addition to all the recommended care with the care environment (including chair covered with disposable sheets) and contaminated materials [32], [33], [34], [35]. In outpatient care, it is recommended to guide the patient to come to the consultation wearing a mask, with the skin lesions covered, without a companion (who may be contaminated), and not bringing personal objects are also considered preventive measures [32].
During care, the patient should be instructed not to move around too much to minimize the chances of rupture of the skin lesions, which would increase the risk of spreading the virus present in these lesions [32].
Conclusions
Oral lesions can be initial foci of MP, are symptomatic, and can be part of the early diagnosis of MP and its consequent treatment, improving the prognosis and quality of life of the affected patient.
Notes
Competing interests
The authors declare that they have no competing interests.
Authors’ ORCID
- Raquel D’Aquino Garcia Caminha:
https://orcid.org/0000-0002-8361-3894 - Gabriel de Toledo Telles-Araujo:
https://orcid.org/0000-0002-9577-2008 - Gabriel Araujo-Silva:
https://orcid.org/0000-0003-2235-9519 - Liliane Lins-Kusterer:
https://orcid.org/0000-0003-3736-0002 - Paulo Sérgio da Silva Santos:
https://orcid.org/0000-0002-0674-3759
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