Antiviral may have eliminated eye inflammation caused by monkeypox

A Brazilian patient with eye complications caused by monkeypox improved after being treated with the antiviral tecovirimat. In addition to the positive response to the drug, this is the first record of a type of inflammation in that organ related to monkeypox.

The finding is part of an article published this Thursday (22) in the journal Jama, which analyzed the case of a 27-year-old boy treated at Clínica de Olhos Dr. Moacir Cunha, from Grupo Fleury in São Paulo.

Inoculation of the virus in the eyes occurs when the infected person touches some lesion (one of the main symptoms of the disease), where there is a high viral load, and takes his hand to the eye region. One reported outcome is conjunctivitis: one survey concluded that 23% of patients infected with monkeypox virus between 2010 and 2013 in the Congo had the complication. More extreme scenarios also occur, such as people who have lost their eyesight.

In the current outbreak, considered a public health emergency by the WHO (World Health Organization), such cases are rare. One of the few examples is that of the Brazilian who had his clinical condition reported in the new Jama article. Signed by Brazilian researchers, the publication says that the patient is a 27-year-old man who went to Clínica de Olhos Dr. Moacir Cunha, from Grupo Fleury, in August, with a red left eye, showing sensitivity to light, pain, itching and low vision.

The boy’s diagnosis was keratitis and uveitis: the first is an inflammation of the eye’s cornea, while the second is also an inflammation, but intraocularly, that is, inside the eye.

The patient reported a positive test for monkeypox, with the first lesion common to monkeypox seen 24 days before seeking eye care – the illness was almost completely overcome when he sought help for his eye problem.

In the beginning, one of the explanations for her eye condition was herpes causing the keratitis. We opted for the use of eye drops and valacyclovir, a drug used in the treatment of herpes. Despite this, the patient continued to deteriorate. Another point was that examinations were done on the patient’s eye for herpes, syphilis and monkeypox. The results for the first two diseases were negative, while the third was positive.

The man showed no signs of recovery in the eye, but this is not the case with monkeypox symptoms. The few lesions of the disease that he still had, after seven days of ophthalmological care, failed to register the DNA of the virus.

So the doctors stopped valaciclovir and started therapy with tecovirimat as soon as the drug became available in Brazil. From the third day of using the antiviral, the patient started to improve and, days later, recovered from the inflammation in the eye.

The results are promising, but not final. “Based on this case, we cannot say that it was the antiviral that cured the patient”, says Luciana Peixoto Finamor, ophthalmologist at Clínica de Olhos Dr. Moacir Cunha, in São Paulo, and one of the authors of the article.

Some points, however, tend to indicate this. The main thing is the fact that the patient begins to show signs of improvement soon after using the antiviral. According to Finamor, it took about two months with the eye exam registering the virus, a situation that only changed with the medicine.

“After the treatment, he was ‘negative’. So it’s one more tool that shows that the antiviral made a difference in controlling the disease [inflamação no olho]”, he states.

Finamor also says that, in addition to this case, about 8 to 10 Brazilians have already had ocular complications from monkeypox and have been treated with tecovirimat. Similar cases have also been documented in the United States. She mentions a study by the CDC (Center for Disease Control of the USA) that observed positive results of the antiviral for five patients with ocular complications associated with the viral infection. None of them, however, had uveitis.

This is because, according to Finamor, the Brazilian was the first patient with uveitis associated with monkeypox. The originality raises concern, since the complication is characterized as intraocular.

“The eye, theoretically, is a contiguity of the central nervous system. So, if we have the presence of inflammation related to this disease inside the eye, this could be an opportunity for dissemination to the central nervous system”, he concludes.