On July 14, architect Rodrigo (not his real name), 39, saw something resembling an ingrown hair in the genital region. He didn’t pay much attention. Three days later, on Sunday, he had a fever and chills, but after taking paracetamol, he felt better.
In the second, he woke up still indisposed and imagined that it could be the flu. In the afternoon, however, another lesion, similar to a pimple, appeared in the palm of the hand. “Then, as I had never seen an ingrown hair or pimple on the palm of my hand, I ran after an infectious disease specialist, already sure it was monkeypox.”
On Tuesday, when he was consulted, there were five pustules in total: two in the genital region, two on the hands and one on the foot. The next day, he took the exam and the diagnosis came: it was the monkeypox virus, which has infected more than 800 people in Brazil.
“The worst thing was the fright of being faced with a new disease. Looking on the internet, the images are very ugly. For me it was nothing like that, not even because of the number of lesions, the size or appearance”, says Rodrigo, who was treated in home and is cured. He has a partner who has not been infected. Both have sex with other men.
The case of the architect is no exception. Infectologists report that the appearance of more subtle cases, which do not resemble the classic presentation of monkeypox described in the literature, has been frequent, with symptoms that include fever, headache, inflammation of the lymph nodes, followed by lesions, pustules in various parts. of the body, which later turn into crusts.
This difference can delay the search for medical help, confuse health professionals who are not trained in the diagnosis and contribute to the dissemination of cases, according to doctors.
Infectologist Rosana Richtmann, from the Emílio Ribas Institute, says that she has treated patients with monkeypox in both the SUS and in her private practice who have much more subtle lesions than what appear in scientific articles and news about the disease.
In general, they are small pustules with yellowish content that can appear on various parts of the body, such as the face and genital and anal regions, but not necessarily all at the same time.
“MSM groups [homens que fazem sexo com homens] they are more attached to any lesion that appears on the skin and come to us right away. But usually they don’t look for fever, chills, none of that.”
Infectologist Alexandre Naime Barbosa, professor at Unesp (Universidade Estadual Paulista) and vice president of the Brazilian Society of Infectious Diseases, says that he saw a patient who had only a small lesion on his face, in the region below the lip, which looked like a pimple.
“But as he already does Prep [terapia de prevenção ao HIV] with me and had had oral sex with several partners, he was worried, he made an appointment, we tested and it was [o vírus] monkeypox.”
Infectologist Esper Kallás, professor at USP and columnist for Sheethas also observed atypical or subclinical lesions in patients diagnosed with monkeypox.
“Sometimes, an inflamed tip appears on the leg and the subject thinks it is an ingrown hair. Then a week passes and he has a red ganglion, high fever, feeling unwell. This evolution does not allow the person to make a quick diagnosis.”
According to him, injuries of all types are being observed. “Some are very clear, genital lesions, vesicles, but there are other very strange ones. One guy only had a lesion on his forehead, another boy had a urethral obstruction because the lesion had grown into the urethra.”
For Richtmann, there are so many differences between the classic presentation of monkeypox seen in Africa and that currently observed in Europe, the United States and Brazil that the disease deserves another name.
According to doctors, vesicles often become infected because they serve as a gateway for bacteria. “That’s why it’s important not to scratch the lesion to avoid becoming a secondary infection”, explains the doctor.
In general, healing occurs within two to four weeks. During this period, it is essential that the infected person remains isolated.
Another concern of specialists is the cases of asymptomatic people who, without knowing they have the disease, continue to transmit it. A small study done in Belgium showed that up to 13% of people can have the virus detected in the anus or penis and be without symptoms.
“It’s a long-incubation disease, after infection it can take up to three weeks for the
appearance of symptoms. This all makes contingency very difficult. The way is to increase clinical suspicion. Anyone who has an erythematous lesion, who starts to blister, has to be considered a suspect”, says Barbosa.
But, according to the infectologist, this is not happening. “These patients need to be isolated and tested to break the chain of transmission. The Ministry of Health’s own definition of monkeypox needs to be updated in light of the current clinical presentation of the disease”, he says.
“The federal government, like what happened with Covid, continues with a lack of risk perception about monkeypox. What we are seeing now is the splinter of the crumb, the lint from the tip of the iceberg. placed on suspicion, adequate amounts of testing are being done.”
For the doctor, it is necessary to make it clearer that it is not a disease that only affects the population of men who have sex with men. “It started in this population and still has a very high prevalence in it, but the world already has more than 70 cases in children. The disease is democratic.”
He says that the MSM population is the least cause for concern because they already know the risks and seek help quickly when they notice something is wrong. “The general population, on the other hand, because of stigmatization and the same mistake we made in relation to HIV, does not feel at risk.”
In his opinion, it is necessary for the country to speed up access to the vaccine to be able to stop transmission in the highest risk groups. “How are you going to tell people not to touch, not to hug, not to kiss and not to have sex?”
On Saturday (23), the Minister of Health, Marcelo Queiroga, said that the federal government is negotiating with PAHO (Pan American Health Organization) the acquisition of vaccines through the revolving fund, an international mechanism of technical cooperation for access to vaccines, but that there is still no deadline for this.
Esper Kallás also considers it essential to vaccinate the groups at greatest risk, such as the MSM population and health professionals, as is already done in Europe and the USA. “We also need more speed to strengthen the information, diagnosis and notification chains, in addition to mapping the epidemiological distribution.”
Another point is the offer of drugs to treat some more complicated cases of monkeypox. Tecovirimat and brincidofovir are drugs indicated for this purpose, but neither is available in Brazil.
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