A Call for Attention: Pediatric Monkeypox Case in a Context of Changing Epidemiology : The Pediatric Infectious Disease Journal

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Letters to the Editor

A Call for Attention: Pediatric Monkeypox Case in a Context of Changing Epidemiology

Fuente, Sara Monje MD; Nava, Francisco de Borja MD; Valerio, Maricela MD, PhD; Veintimilla, Cristina MD; Aguilera-Alonso, David MD

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The Pediatric Infectious Disease Journal: December 2022 - Volume 41 - Issue 12 - p e548-e549
doi: 10.1097/INF.0000000000003695
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To the Editors:

Considering the major outbreaks of monkeypox reported in nonendemic areas, as well as the changing epidemiology, there is a need to highlight the difficulties in diagnosing monkeypox infection in children, given the current low index of suspicion.

Monkeypox is a zoonotic disease described in 1970 as endemic in West-Central African countries.1 However, from May 2022 onwards, the highest outbreaks have been reported in nonendemic countries. Nowadays, Spain is the most affected country in Europe.2

There are currently few publications on pediatric cases in nonendemic countries, and even fewer without a clear epidemiologic background. The current health alert focuses on sex-related transmission, yet transmission may occur through respiratory droplets, contact with fluids or lesions unrelated to sex, and through fomites.3,4

Prodromal symptoms have been described, followed by characteristic skin lesions. Involvement seems to be more severe in children under 10 years of age. The mortality rate described in African countries ranges from 3% to 10%.1,3

This letter is written to describe a case that posed a diagnostic challenge in our center, as it did not refer any compatible epidemiologic background. A 13-month-old boy came to the pediatric emergency room due to vomiting, diarrhea and fever for 48 hours. He presented a purulent blistering lesion on a finger and crusty lesions on the scalp and on a toe. Close relatives did not report any symptoms or traveling abroad in the last months.

The blistering lesion was drained taking a sample for bacterial culture (Fig. 1A) and oral amoxicillin-clavulanate was prescribed. Methicillin-resistant Staphylococcus aureus was isolated, and treatment was changed to trimethoprim-sulfamethoxazole. After 48 hours, he presented a new gluteal warm and swollen lesion. The lesion evolved into an abscess and was drained (Fig. 1B).

General caption: Monkeypox lesions. A: Blistering lesions with a total loss of epidermis and dermis and exposition of the tendon. B: Vesicle, which evolved into a pustule, and later to an abscess in the gluteal region.

Despite the methicillin-resistant S. aureus infection, the epidemiologic alert and suggestive lesions led us to request a monkeypox virus polymerase chain reaction, which was positive. The patient evolved favorably. Fever and gastrointestinal symptoms ceased after 5 days.

The case was notified to the Epidemiological Surveillance Network. Family members and other close contacts did not show any monkeypox signs. Monkeypox polymerase chain reaction testing in pharyngeal swabs and blood samples taken from family members were negative. After a detailed epidemiologic survey, an index case was not detected. To note, he was not attending a kindergarten. Sexually transmitted infections (HIV, syphilis, hepatitis B and C) were excluded.

This letter aims to:

  1. Alert about the increasing community transmission of monkeypox in children, and the need to suspect it even in the absence of a clear epidemiologic background.
  2. Highlight that bacterial infections could obscure a potential case of monkeypox. Clinical suspicion should lead to a diagnostic monkeypox test even with bacterial isolation as bacterial superinfections are common.5
  3. Call for the need to create specific protocols for pediatric patients to face the challenges posed by this global outbreak.
  4. Emphasize that multidisciplinary work between pediatricians, pediatric surgeons and microbiologists is essential to reach the diagnosis and should be considered to detect, treat and trace new cases.


1. Bunge EM, Hoet B, Chen L, et al. The changing epidemiology of human monkeypox-A potential threat? A systematic review. PLoS NeglTrop Dis. 2022;16:e0010141.
2. European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Monkeypox, joint epidemiological overview. 2022. Available at: https://monkeypoxreport.ecdc.europa.eu/. Access date: 29 July 2022.
3. European Centre for Disease Prevention and Control. Risk assessment: monkeypox multi-country outbreak. 2022. Available at: https://www.ecdc.europa.eu/en/publications-data/risk-assessment-monkeypox-multi-country-outbreak.
4. Tutu van FA, van der Kuip M, van Els AL, et al. Paediatric monkeypox patient with unknown source of infection, the Netherlands, June 2022. Euro Surveill. 2022;27:2200552. Access date: 29 July 2022.
5. Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox virus infection in humans across 16 countries — April–June 2022. N Engl J Med. 2022. Published online.

children; community transmission; epidemiological outbreak; monkeypox

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