
==== Front
Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

10.1097/MS9.0000000000000082
00041
3
Correspondence
Potentially devastating monkeypox outbreak amidst COVID-19 pandemic in Pakistan
http://orcid.org/0000-0003-4199-4518
Siddiqui Noor N. noornaveed.siddiqui18@dmc.duhs.edu.pk

Riaz Kainat kainat.riaz18@dmc.duhs.edu.pk

Nisa Tahzeeb-u tehzeebbashir1@gmail.com

Hussain Syed M. syedmesum.hussain1998@gmail.com

Dow University of Health Sciences, Karachi, Pakistan
* Corresponding author. Address: Dow University of Health Sciences, Karachi 75290, Pakistan. Tel.: +923342931486. E-mail address: kainat.riaz18@dmc.duhs.edu.pk (K. Riaz).
3 2023
17 2 2023
85 3 553554
9 10 2022
11 12 2022
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
2023
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. http://creativecommons.org/licenses/by-nc-sa/4.0/

OPEN-ACCESSTRUE
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pmc To the Editor,

Monkeypox virus (MPXV) is a rare virus that belongs to the genus Orthopoxvirus and the family Poxviridae. This virus causes a zoonotic disease with symptoms that can be described as a less severe form of smallpox. The first symptoms of the disease appear after a week or two following infections as a rash or blisters followed by shivers, headaches, and fainting, with lymphatic hyperplasia being the most common and useful symptom for diagnosing this disease. MPXV is clinically transmitted through bodily fluids such as blood and urine, lesions on the skin, and contaminated objects like towels and clothing1. MPXV was first discovered in monkeys in 1958, with the first human case reported on 1 September 1970, in the Democratic Republic of the Congo2. It is reported that the majority of infections were found in men who have sex with men3. Since the re-emergence of monkeypox in 2022, the first case of the virus was reported in Nigeria (where it is endemic) on 6 May 2022. After May, clusters of cases were reported outside of West Africa with reporting a total of 79,151 confirmed cases as of 10 November 20224. In Pakistan, two patients that showed symptoms of rashes and blisters were admitted under the suspicion of contracting MPXV to the National Institute of Child Health. However, the National Institutes of Health dismissed those two cases as they tested negative and clarified that no case of the relevant virus has been diagnosed as of yet5.

Recent data and findings collected from the study of infected individuals indicate a few unique clinical presentations such as single genital lesions and ano-oral sores and ulcers. These ano-oral symptoms can cause severe pain in infected individuals, manifesting as difficulty swallowing and requiring subsequent hospitalization6. These crucial symptoms are closely related to those of traditional sexually transmitted infections; therefore, they should be kept under consideration to prevent the incidence of misleading diagnoses.

Thus, the combination of scarcity of adequate equipment, a lack of widespread awareness, financial instability, low resources due to the global coronavirus disease-2019 (COVID-19) pandemic, and the chance for misdiagnosis can have a huge effect in third-world countries. This can leave the population in a devastated state by causing gaps in rapid interventions of diagnosis which can hinder protective measures such as timely emergency management and establishment of immediate surveillance. It was also seen that patients who were once infected with COVID-19 are more prone to stress, particularly those who are already immunocompromised, oncologic, and individuals with comorbidities7. Eventually, the ratio of undiagnosed cases may rise due to the lack of abrupt identification of cases. This can lead to a surging monkeypox epidemic.

Pakistan is a third-world country that cannot manage another pandemic due to a lack of existing healthcare infrastructure, as demonstrated by the response to the COVID-19 pandemic8. The MPXV virus is endemic to many nations, but its potential to cause another pandemic is not yet known. While it is possible that Pakistan can handle the burden of the MPXV virus, there is also cause for concern that this virus may overwhelm an already overburdened healthcare system. The government must hence take immediate action, focus on its prevention, and be prepared to handle its spread in case of a rapid outbreak in Pakistan.

Ethical approval

Not applicable.

Sources of funding

None.

Author contribution

N.N.S.: study conception, write-up, critical review, and approval of the final version; K.R.: study conception, write-up, critical review, and approval of the final version; T.-u-N.: study conception, critical review, and approval of the final version; S.M.H.: study conception, critical review, and approval of the final version.

Conflicts of interest disclosure

The authors have no conflicts of interest.

Research registration unique identifying number (UIN)

1. Name of the registry: not applicable.

2. Unique identifying number or registration ID: not applicable.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable.

Guarantor

K. Riaz and S.M. Hussain.

Provenance and peer review

Not commissioned, externally peer reviewed.

Patient consent

Not applicable.

Disclaimer

Not applicable.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 17 February 2023
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References

1 Reynolds MG Yorita KL Kuehnert MJ . Clinical manifestations of human monkeypox influenced by route of infection. J Infect Dis 2006;194 :773–80.16941343
2 CDC. Monkeypox in the U.S. Centers for Disease Control and Prevention; 2022. Accessed October 4, 2022. https://www.cdc.gov/poxvirus/monkeypox/about/index.html
3 Kimball S . WHO recommends gay and bisexual men limit sexual partners to reduce the spread of monkeypox. CNBC. Accessed October 4, 2022. https://www.cnbc.com/2022/07/27/monkeypox-who-recommends-gay-bisexual-men-limit-sexual-partners-to-reduce-spread.html
4 Monkeypox Data Explorer. Our World in Data. Accessed October 4, 2022. https://ourworldindata.org/explorers/monkeypox
5 No monkeypox case reported in Pakistan yet. Accessed October 4, 2022. https://www.thenews.com.pk/print/960515-no-monkeypox-case-reported-in-pakistan-yet
6 Queen Mary University of London. Accessed October 4, 2022. https://www.qmul.ac.uk/media/news/2022/smd/new-clinical-symptoms-identified-in-largest-international-case-study-series-of-confirmed-monkeypox-cases-.html
7 Malik P Patel K Pinto C . Post-acute COVID-19 syndrome (PCS) and health-related quality of life (HRQoL)—a systematic review and meta-analysis. J Med Virol 2022;94 :253–62.34463956
8 COVID-19 and arboviral diseases: another challenge for Pakistan’s dilapidated healthcare system. Abstract – Europe PMC. Accessed October 4, 2022. https://europepmc.org/article/pmc/pmc7753522
