Mpox in Eastern Europe: Clinical findings from a Polish case series

Dear Editor,

Following the recent global outbreak of Clade II monkeypox (Mpox), we wish to report clinical observations from one of the first case series in Poland and Eastern Europe. Sixteen men diagnosed with Mpox were hospitalized between July and September 2022 at the Department of Infectious Diseases, Józef Struś Multispecialist City Hospital in Poznań. While the clinical presentation of Mpox has been well described, our findings provide insight into patient profiles and comorbidities in a Central European setting.

All patients were men aged 24–41 years; 75% reported sexual contact with men. Twelve patients were Polish nationals, and the remainder were American, Russian, Ukrainian, or of unknown nationality. Over two-thirds had a history of sexually transmitted infections (STIs), including HIV (7/16, 43.75%), syphilis (7/16, 43.75%), gonorrhoea, hepatitis A, and chlamydia. Nine patients reported recent travel abroad or contact with foreign partners, underscoring the cross-border nature of transmission.

All patients presented with cutaneous lesions, predominantly in the genital-anal region (100%). Facial involvement was observed in 62.5%, and 43.75% had lesions covering the entire body. Lesions on the trunk, extremities, and face were also frequent. General symptoms included fever (50%), inguinal lymphadenopathy (37.5%), myalgia or arthralgia (25%), pharyngitis and shivering (25%). Other reported symptoms included asthenia (12.5%), dyschezia, hematochezia, and burning sensation in the anal area. The average hospitalization lasted 11 days.

Among people living with HIV, 43% had disseminated lesions and 40% had facial involvement. Systemic symptoms such as fever, lymphadenopathy, and musculoskeletal pain were more common in this group. Similar associations were observed in patients with syphilis. For example, 57% of patients with syphilis had disseminated skin involvement and 67% had inguinal lymphadenopathy. These comorbidities appeared to correlate with a more severe course of disease.

Of note, one patient presented with Mpox alongside HIV and active syphilis. He exhibited vesiculopustular and ulcerative lesions across multiple body regions, including the penis and scrotum, accompanied by fever and lymphadenopathy. Due to penicillin allergy, he was treated with ceftriaxone and azithromycin, with full resolution of symptoms. Our findings align with previous reports indicating that co-occurring STIs may mask or modify the clinical picture of Mpox and increase the risk of complications.^1,2

C-reactive protein (CRP) levels were elevated mainly in patients with comorbidities, but not consistently in those with HIV, consistent with earlier findings that CRP levels may remain unaffected by HIV status. ³ The highest CRP values were recorded in patients with multiple infections or systemic bacterial inflammation. Despite the systemic presentation in several patients, no cases of sepsis or need for intensive care were recorded.

These findings highlight the importance of thorough epidemiological and sexual history-taking and screening for STIs in Mpox patients. In our cohort, the absence of stable relationships and frequent international contact were common, supporting the role of behavioral and social factors in transmission.^4,5

This series emphasizes that even in non-endemic countries, Mpox can present with a range of systemic and mucocutaneous symptoms, particularly among men who have sex with men and people with underlying STIs. We recommend including Mpox in the differential diagnosis of genital ulcers, particularly in patients with risk factors such as multiple partners or STI history. Awareness, early diagnosis, and integrated management are critical.