Letters to the Editor.

Abstract

Monkeypox (MPOX) is a zoonotic viral disease caused by an orthopoxvirus that is endemic in West and Central Africa. Since May 2022, there has been a sudden increase in disease cases in non-endemic countries, with Brazil accounting for 12% of reported cases world-wide (https://ourworldindata.org/monkeypox). The highest prevalence of MPOX in the current outbreak is found in the anogenital region among gay/bisexual male young adults with high-risk sexual behaviour.1 MPOX in children and adolescents aged <18 years has been described infrequently, but a recent nationwide ecological study reported that approximately 5% of cases in Brazil were diagnosed in the paediatric population.2 Here, we present a case series of children and adolescents with MPOX in Sergipe state, North-East Brazil, recognised as one of the poorest regions in the country. All cases were diagnosed between 22 August 2022 and 18 January 2023. Samples were obtained from skin lesions, and all were positive for MPOX DNA using real-time polymerase chain reaction.3 The following demographic and clinical variables were described: sex, age, diagnosis, potential transmission route, signs and symptoms, need for hospitalisation and deaths. During the study period, 71 cases of MPOX were reported in Sergipe state, of whom 15 (21.1%) were diagnosed among individuals aged <18 years. The ages of the 15 affected children ranged from 6 months to 15 years (median 12 years), with males accounting for 9 (60%) of cases. Three patients (20%) were asymptomatic, and 12 (80%) had systemic symptoms, particularly fever (75%), headache (41.7%), asthenia (25%), myalgia (16.7%) and sore throat (16.7%). All children with MPOX had skin and/or mucosal lesions, which were found in the upper and/or lower limbs (80%), torso (73.3%), face (33.3%), oral mucosa (13.3%), penis (6.7%) and inguinal region (6.7%). Four (26.7%) children had close household contact with a confirmed case up to 3 weeks before the onset of the lesions. No hospitalizations or deaths were recorded (Table 1). MPOX prevalence among children and adolescents aged <18 years in Sergipe state was found to be four times higher than the overall estimate in Brazil2 and 70 times higher than in the United States.4 These findings may indicate a change in the disease's epidemiological profile in some geographical areas. Furthermore, the lesions observed in the paediatric population appear to be concentrated in anatomical regions that are less commonly affected in adults, possibly due to differences in how the virus is transmitted.5, 6 In adults, most lesions occur in the anogenital region among men who have sex with men, and inguinal lymphadenopathy is common. Despite the very low risk of unfavourable clinical outcomes, our findings highlight the need for improved disease surveillance in this population, as well as educational and preventive measures for those who care for children.