article · American Journal of Tropical Medicine and Hygiene
Enhanced surveillance in the Democratic Republic of Congo confirmed that coinfections of monkeypox virus and varicella zoster virus occur in an endemic setting. Between September 2009 and April 2014, laboratory testing identified coinfections in 134 out of 1,107 suspected monkeypox cases, representing 12.1 per cent of the evaluated group. Patients with coinfections displayed distinct clinical profiles when compared to individuals infected with either virus alone. Lesion counts in coinfected patients were significantly higher than those seen in varicella zoster virus alone, yet lower than those recorded in monkeypox alone. Similarly, coinfected individuals were more likely to report symptoms than those with varicella zoster virus alone, but less likely than monkeypox-only cases. These variations suggest that simultaneous infection modulates disease severity. Gathering multiple lesion samples per patient proved essential for uncovering these dual infections during surveillance activities.
Monkeypox and chickenpox present similar rash symptoms, which can complicate accurate diagnosis in endemic regions. Demonstrating that simultaneous infections occur in more than one in ten suspected cases reveals an overlooked layer of disease presentation. Understanding how dual infections alter symptom severity helps clinicians recognise complex cases and highlights the necessity of testing multiple lesions to avoid misdiagnosis during disease outbreaks.
The findings inform diagnostic protocols and surveillance tools for public health agencies and clinical diagnostics developers. Multiplex diagnostic tests capable of detecting both monkeypox and varicella zoster virus simultaneously from patient samples could improve clinical triaging. While the underlying clinical surveillance is applied and established in field conditions, developing integrated commercial diagnostic assays or field tests based on these sampling protocols remains at an early developmental stage.
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Recent enhanced monkeypox (MPX) surveillance in the Democratic Republic of Congo, where MPX is endemic, has uncovered multiple cases of MPX and varicella zoster virus (VZV) coinfections. The purpose of this study was to verify if coinfections occur and to characterize the clinical nature of these cases. Clinical, epidemiological, and laboratory results were used to investigate MPX/VZV coinfections. A coinfection was defined as a patient with at least one Orthopoxvirus/MPX-positive sample and at least one VZV-positive sample within the same disease event. Between September 2009 and April 2014, 134 of the 1,107 (12.1%) suspected MPX cases were confirmed as MPX/VZV coinfections. Coinfections were more likely to report symptoms than VZV-alone cases and less likely than MPX-alone cases. Significantly higher lesion counts were observed for coinfection cases than for VZV-alone but less than MPX-alone cases. Discernible differences in symptom and rash severity were detected for coinfection cases compared with those with MPX or VZV alone. Findings indicate infection with both MPX and VZV could modulate infection severity. Collection of multiple lesion samples allows for the opportunity to detect coinfections. As this program continues, it will be important to continue these procedures to assess variations in the proportion of coinfected cases over time.
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DOI: 10.4269/ajtmh.20-0589
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