A recent case report published in the journal JACC Case Reports indicated that monkeypox infection might be associated with acute myocarditis or heart muscle inflammation.
Clincal Case: Acute Myocarditis – a new manifestation of Monkeypox infection? Image Credit: Lightspring / Shutterstock
Monkeypox infection
Monkeypox is a zoonotic virus that causes mild to moderate infection in humans, lasting 2 to 4 weeks. The most common symptoms are fever, skin rashes or lesions, and lymph node swelling. However, in some cases, infections can lead to severe medical complications. Currently, the case fatality ratio of monkeypox infection has been estimated to be 3-6%.
Case presentation
The case report described the medical manifestations of a 31-year-old male patient with laboratory-confirmed monkeypox infection. The patient developed malaise, myalgias, fever, and multiple skin lesions on his face, hands, and genitalia and presented to the clinic.
Three days after monkeypox detection, he presented to the emergency department because of chest heaviness that disrupted his night-time sleep. His physical examination revealed multiple severe skin lesions on his face, wrists, thighs, and genitalia. He also had one ulcerated lesion on the penis, painful swelling of the foreskin and glans, and lymph node swelling.
Medical history of the patient
The patient had a mild infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) two months before the diagnosis of monkeypox infection. In addition, he was treated with pre-exposure prophylaxis against human immunodeficiency virus (HIV) due to sexual risk exposure (men who have sex with men).
Except for tobacco use and occasional cannabis use, he did not mention consuming any other illicit drugs or alcohol.
Clinical investigations
The electrocardiography (ECG) findings of the patient revealed ventricular repolarization abnormalities. However, a normal cardiothoracic index was observed in the chest x-ray examination. Regarding biochemical parameters, increased levels of C-reactive protein, creatine phosphokinase, troponin I, and brain natriuretic peptide were observed.
Based on the clinical findings, the patient was suspected of having acute myocarditis (heart muscle inflammation) and was admitted to the intensive care unit under airway isolation. After 24 hours of admission, cardiac magnetic resonance was performed, which revealed myocardial inflammation, edema, and necrosis. Based on these findings, the diagnosis of acute myocarditis was confirmed.
The patient was treated with supportive care and exercise restriction and had a complete clinical recovery. The treatment with non-steroidal anti-inflammatory drugs was terminated.
Significance
This case report highlights the possibility of cardiac manifestations in patients with monkeypox infection. This finding might help physicians to make appropriate diagnostic and therapeutic decisions.
Both monkeypox and smallpox viruses belong to the orthopoxvirus family. Although more aggressive than monkeypox infection, smallpox infection is known to associate with myocarditis. Cardiac complications have also been noticed in individuals immunized with smallpox vaccines. Thus, being a related virus, monkeypox may also have a tropism for cardiac tissue, justifying the incidence of acute myocarditis in a monkeypox-infected patient.
Based on the case findings, the scientists suggest that cardiac magnetic resonance is an effective non-invasive method for the clinical diagnosis of viral myocarditis. Furthermore, in patients without indications for endomyocardial biopsy (EMB), cardiac magnetic resonance can be used to avoid invasive procedures.
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