モンキーポックスでこんな症例もあるらしい 性感染症類似の症例 : ずくなしの冷や水


モンキーポックスでこんな症例もあるらしい 性感染症類似の症例

Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash
Dr. Vivian De Oliveira Rodrigues Gama (Medicine): A 31-year-old man was admitted to this hospital because of perianal and penile ulcers, rectal pain, and vesiculopustular rash.

The patient had been in his usual state of health until 9 days before this admission, when he noticed several itchy white “bumps” around the anus that subsequently evolved into ulcerative lesions. The next day, he sought evaluation at a primary care clinic of another hospital. Tests for human immunodeficiency virus (HIV), syphilis, gonorrhea, and chlamydia were performed. An injection of penicillin G benzathine was administered, and treatment with valacyclovir was started.

During the next 5 days, the perianal ulcers did not abate, and the patient stopped taking valacyclovir. Painful proctitis with rectal bleeding and malodorous, mucopurulent discharge developed, along with fever, chills, drenching sweats, and new tender swelling in the groin. Three days before this admission, a new painless ulcer appeared on the penis that was similar in appearance to the perianal ulcers. Two days before this admission, new scattered vesicular lesions appeared on the arms and legs, and the patient presented to the infectious disease clinic of this hospital for evaluation.

Additional history was obtained from the patient. Fourteen years before this evaluation, sore throat and upper body rash developed; he received a diagnosis of secondary syphilis and was treated with penicillin G benzathine. He also had a history of recurrent oral herpes simplex virus (HSV) infection, for which he was treated intermittently with valacyclovir. He took daily oral emtricitabine and tenofovir for HIV preexposure prophylaxis (PrEP). There were no known drug allergies.

The patient lived in a suburban area of Massachusetts with two roommates and a cat. Two weeks before this evaluation, he had traveled to an urban area of southeastern Canada. During this trip, he had had sex with male partners without the use of barrier protection. There was no other recent travel. The patient did not smoke cigarettes or use illicit drugs; he drank alcohol rarely.
Vivian De Oliveira Rodrigues Gama医師(医学)。31歳の男性が,肛門周囲と陰茎の潰瘍,直腸痛,小水疱性発疹のため当院に入院した。

患者はこの入院の9日前まで通常の健康状態であったが,肛門周囲の数個のかゆみを伴う白い "こぶ "に気づき,その後潰瘍性病変に発展した。翌日,他院のプライマリーケアクリニックで診察を受けた.ヒト免疫不全ウイルス(HIV),梅毒,淋病,クラミジアの検査が行われた。ペニシリンGベンザチンの注射が行われ,バラシクロビルの投与が開始された.


患者から追加の病歴を聴取した。14年前に咽頭痛と上半身の発疹が出現し,二次梅毒と診断され,ペニシリンGベンザチンで治療された.また,口腔内単純ヘルペスウイルス(HSV)感染症の再発歴があり,バラシクロビルで断続的に治療していた.HIVのPrexposure Prophylaxis(PrEP)のためにemtricitabineとtenofovirを毎日経口投与していた。既知の薬物アレルギーはなかった。




Laboratory Diagnosis

Infection with monkeypox virus, West African clade.
Contact Tracing and Exposure Investigation

Dr. Shenoy: While awaiting confirmation of the diagnosis, we began the process of contact tracing and exposure investigation to identify and subsequently assess risk for persons with confirmed exposure to the patient during the period when he was not isolated. This period included his outpatient visits, an encounter in the emergency department, and his inpatient admission. All health care personnel with a confirmed exposure of any risk level (high, intermediate, or low or uncertain) were monitored for symptoms. We worked with the Massachusetts Department of Public Health to identify options for postexposure prophylaxis for persons with high-risk exposures or with specific intermediate-risk exposures.
Public Health Considerations

Dr. Brown: Once the diagnosis of monkeypox was established, epidemiologists from the Massachusetts Department of Public Health coordinated with the hospital to initiate case investigation and contact tracing. Interviews of the patient elicited an epidemiologic profile consistent with that observed in other recent cases, including no history of travel to an endemic region and no known contacts with monkeypox. Contact tracing initially identified more than 200 possible contacts among health care personnel and personal contacts. Further assessment, performed with the application of criteria for exposure risk level, reduced this number. Contacts with an exposure of any risk level are to be monitored for symptoms (fever or chills, lymphadenopathy, and rash) for 21 days after the exposure. Monitoring is to be overseen by the public health department or health care institution; frequent communication between contacts and monitors is advised.11

Dr. Lawrence C. Madoff: Smallpox vaccination provides protection against monkeypox; however, routine smallpox vaccination in the United States ended in 1972, after disease eradication. Thus, postexposure prophylaxis with the use of the smallpox (vaccinia) vaccine (ACAM2000) or the smallpox and monkeypox vaccine (JYNNEOS) is recommended after high-risk exposures and can also be considered for intermediate-risk exposures. Given its safety profile and ease of administration, JYNNEOS, which has been approved by the Food and Drug Administration for the prevention of both smallpox and monkeypox,11,12 was obtained from the Strategic National Stockpile and made available to occupational health services at the hospital. Within the first week after diagnosis, several contacts were tested for monkeypox, and none had positive tests.

Current guidance indicates that infected persons should remain in isolation until all skin lesions have resolved and a fresh layer of skin has grown. Because this patient had mucous membrane lesions, reepithelialization of ulcerated mucosal surfaces was thought to be required.

Most patients with monkeypox have mild, self-limited disease and are treated with supportive care only, but some patients have severe disease. Currently, no medical countermeasures have been approved for the treatment of monkeypox. However, two antiviral agents (tecovirimat and cidofovir) and vaccinia immune globulin intravenous are available in the Strategic National Stockpile as options for treatment. To date, among reported cases in the United States in the current outbreak, at least one patient has been treated with tecovirimat.13 These medical countermeasures should be considered in patients with monkeypox who have severe disease or have a high risk of severe disease, including immunocompromised patients, children, pregnant or breast-feeding patients, and those with one or more complications of illness. In accordance with current CDC recommendations, treatment should also be considered in patients with monkeypox caused by accidental implantation in the eyes, mouth, or other areas.14


Dr. Shenoy:診断の確定を待つ間、私たちは、患者が隔離されていなかった期間に接触したことが確認された人物を特定し、その後リスクを評価するために、接触追跡と曝露調査のプロセスを開始しました。この期間には、患者の外来受診、救急部での診察、入院が含まれる。リスクレベル(高、中、低、不明)にかかわらず、曝露が確認されたすべての医療従事者は、症状をモニターされた。マサチューセッツ州公衆衛生局と協力して、高リスクの曝露を受けた人や特定の中リスク曝露を受けた人に対する曝露後予防の選択肢を明らかにした。

ブラウン博士 サル痘の診断が確定すると、マサチューセッツ州公衆衛生局の疫学者が病院と連携して、症例調査と接触者追跡を開始しました。患者への聞き取り調査では、流行地への渡航歴がなく、サル痘との接触も知られていないなど、最近の他の症例と一致した疫学的プロファイルが得られました。接触者追跡の結果、医療従事者および個人的な接触者の中から200人以上の接触者の可能性があることが判明しました。さらに、曝露リスクレベルの基準を適用して行われた評価により、この数は減少しました。あらゆるリスクレベルの曝露を受けた接触者は、曝露後21日間、症状(発熱または悪寒、リンパ節腫脹、発疹)について監視されることになっています。モニタリングは、保健所または医療機関が監督することになっており、接触者とモニタリング者の間で頻繁に連絡を取ることが推奨されます11。

ローレンス・C・マドフ博士 しかし、米国における天然痘の定期的な予防接種は、サル痘根絶後の1972年に終了しています。したがって、高リスクの曝露後には天然痘(ワクシニア)ワクチン(ACAM2000)または天然痘・サル痘ワクチン(JYNNEOS)を用いた曝露後予防を推奨し、中リスクの曝露の場合にも検討することが可能である。その安全性と投与の容易さから、天然痘とサル痘の両方の予防に食品医薬品局から承認されているJYNNEOSを戦略的国家備蓄から入手し、病院の産業保健サービスで利用できるようにした。診断後1週間以内に、数名の接触者にサル痘の検査を行ったが、陽性者はいなかった。


サル痘の患者の多くは軽症で自己限定的であり、支持療法のみで治療されるが、中には重症化する患者もいる。現在、サル痘の治療法として承認されている医療用対策はない。しかし、抗ウイルス剤2剤(テコビリマット、シドホビル)およびワクシニア免疫グロブリン静注用を治療の選択肢として戦略的国家備蓄として利用することが可能です。現在までのところ、米国で報告されている今回の感染者のうち、少なくとも1人の患者がテコビリマットによる治療を受けています13。これらの医療対策は、免疫不全患者、小児、妊娠中または授乳中の患者、1つ以上の合併症を持つ患者など、重症化しているか重症化のリスクが高い猿痘患者において検討すべきものです。現在の CDC の勧告に従って、目、口、その他の部位への偶発的な埋め込みによって引き起こされた猿痘の患者にも治療を考慮する必要があります14。

posted by ZUKUNASHI at 10:37| Comment(0) | サル痘
お名前: [必須入力]

メールアドレス: [必須入力]


コメント: [必須入力]