作者对“致编辑的信：人感染猴痘和非典型暴发”的回应

姚开虎

（国家儿童医学中心/首都医科大学附属北京儿童医院/北京市儿科研究所皮肤疾病研究室/儿科学国家重点学科/教育部儿科重大疾病研究重点实验室，北京 100045）

非常感谢Mungmunpuntipantip R和Wiwanitkit V对本人撰写的“知往鉴今：人感染猴痘史及其非同寻常的2022年多国暴发疫情”［1］的关注和评论。正如他们所言，2022 年人感染猴痘（human monkeypox，HMPX）疫情中，病例的临床表现与既往报告也存在相当大的差异，这增强了此次疫情“非同寻常”的特点。

近期，越来越多的数据揭示了2022 年HMPX病例不寻常的临床表现［2-3］。世界卫生组织报告此次疫情中，多数病例没有“发热、肿大淋巴结，继之以离心性皮疹”的典型临床表现，而呈不典型表现，包括：很少甚至仅有单个皮肤病变；
有些病例缺乏皮肤病变，表现为肛门疼痛和出血；
有生殖器或会阴/肛周区病变，但无扩散；
皮肤病变发展不同步；
皮肤病变先于发热、不适和其他全身症状（无前驱期）［4］。单一的生殖器病变、口腔或肛门黏膜病灶是新的HMPX 表现形式，有必要增加到HMPX 的临床描述中，有利于及时识别病例和阻止传播［5］。

Petersen等［6］指出，有关HMPX的大多数知识都是从既往被动的间断监测病例和疫情总结中获得，实际上总体认知尚不够准确。迄今为止，还不能确定我们是否已经观察到所有HMPX 的临床表现类型。从已发表文献来看，HMPX病例皮疹和淋巴结肿大的数量、分布、性质及发热、乏力、头痛、背痛、肌痛等全身症状的突出表现，以及上述症状和体征病程演变关系，不同疫情之间都可能存在着明显的差异。Karem 等［7］对2003 年美国HMPX 病例及其密切接触者的血清学研究还证明，在接种过和未接种过痘苗的个体中都存在无症状的HMPX 感染。2022 年疫情中，9 626 例患者中有8例表现为无症状［8］。

临床各科医生都要重视HMPX 临床表现的多样性。在目前分科实践的模式下，患者因为个体表现的特征，就诊的科室绝不会只限于感染科、皮肤科或性病门诊。

以下是对应的英文翻译。

The author"s response to"Letter to editor:human monkeypox and the atypical outbreak"

I really appreciate the comment from Mungmunpuntipantip R and Wiwanitkit V on my recent published article "Learning from the past: the history of human monkeypox and the atypical multicountry outbreak in 2022"[1]. As the comment, the clinical manifestations of the human monkeypox(HMPX) cases in the 2022 outbreak were quite different from the previous reports, which enhanced the"atypical"characteristics of this epidemic.

Recently, more and more data have revealed the atypical clinical manifestations of HMPX cases in 2022[2-3]. The World Health Organization reported that many cases in this outbreak are not presenting with the classical clinical picture for HMPX (fever,swollen lymph nodes, followed by centrifugal rash).Their manifestations presented atypical features,which included presentation of only a few or even just a single lesion; absence of skin lesions in some cases,with anal pain and bleeding; lesions in the genital or perineal/perianal area which did not spread further;lesions appearing at different (asynchronous) stages of development; the appearance of lesions before the onset of fever, malaise and other constitutional symptoms (absence of prodromal period)[4]. Such single genital lesions and sores on the mouth or anal mucosa are new manifestations of HMPX, and it is necessary to add them to the clinical description of HMPX to help identify cases in time and prevent transmission[5].

Petersen et al.[6]pointed out that most data available on HMPX are obtained from individual case or outbreak reports from passive intermittent surveillance, which do not convey an accurate overall picture. Up to date, it is uncertain whether we have already observed all the clinical manifestation types of HMPX.According to the published literatures, the number, distribution and nature of rashes and lymphadenopathy in HMPX cases, the prominent manifestations of systemic symptoms such as fever,fatigue,headache,back pain,and muscle pain,as well as the temporal variations in the course of the abovementioned symptoms and signs may have obvious different characteristics between the previous outbreaks. Karem et al.[7]performed on serological research on HMPX cases and the contacts following the United States HMPX outbreak in 2003 and provided evidence of asymptomatic infections in some vaccinated and unvaccinated individuals. In the 2022 outbreak, 8 in the 9 626 patients were reported as asymptomatic ones[8].

All clinical doctors should pay attention to the diversity of clinical manifestations of HMPX. In the current mode of clinical practice,the patients can visit any departments associated with their manifestations,not just the infection department, dermatology department or sexually transmitted disease clinic.