Monkeypox-Associated Central Nervous System Disease: A Case Series and Review

Objective: Monkeypox virus (MPXV) disease has been declared a public health emergency by the World Health Orga-nization, creating an urgent need for neurologists to be able to recognize, diagnosis, and treat MPXV-associated neu-rologic disease. Methods: Three cases of MPXV-associated central nervous system (CNS) disease occurring during the 2022 outbreak, and their associated imaging findings are presented, with 2 cases previously published in a limited capacity in a public health bulletin.Results: Three previously healthy immunocompetent gay men in their 30s developed a febrile illness followed by progres-sive neurologic symptoms with presence of a vesiculopustular rash. MPXV nucleic acid was detected by polymerase chain reaction (PCR) from skin lesions of 2 patients, with the third patient having indeterminate testing but an epidemiologic link to a confirmed MPXV disease case. Cerebrospinal fluid demonstrated a lymphocytic pleocytosis, elevated protein, and neg-ative MPXV-specific PCR. In 2 patients, magnetic resonance imaging of the brain and spine demonstrated partially enhanc-ing, longitudinally extensive central spinal cord lesions with multifocal subcortical, basal ganglia, thalamic, cerebellar, and/or brainstem lesions. The third patient had thalamic and basal ganglia lesions. All patients received 14 days of tecovirimat, and 2 patients also received multiple forms of immunotherapy, including intravenous immunoglobulin, pulsed high-dose ste-roids, plasmapheresis, and/or rituximab. Good neurologic recovery was observed in all cases.Interpretation: MPXV can be associated with CNS disease. It is unclear whether this is from a parainfectious immune-mediated injury or direct CNS viral invasion.

Automated summary

This study presents three cases of Monkeypox virus (MPXV)-associated central nervous system (CNS) disease during the 2022 outbreak, with imaging findings and treatment outcomes. The patients, previously healthy immunocompetent gay men in their 30s, developed a febrile illness followed by progressive neurologic symptoms and vesiculopustular rash. MPXV nucleic acid was detected in skin lesions of two patients, with the third patient having an epidemiological link to a confirmed case. Magnetic resonance imaging showed central spinal cord lesions and other brain abnormalities. All patients received tecovirimat treatment, and two also received immunotherapy. Good neurological recovery was observed in all cases.