作者對“致編輯的信：人感染猴痘和非典型暴發”的回應

姚開虎

（國家兒童醫學中心/首都醫科大學附屬北京兒童醫院/北京市兒科研究所皮膚疾病研究室/兒科學國家重點學科/教育部兒科重大疾病研究重點實驗室，北京 100045）

非常感謝Mungmunpuntipantip R和Wiwanitkit V對本人撰寫的“知往鑒今：人感染猴痘史及其非同尋常的2022年多國暴發疫情”［1］的關注和評論。正如他們所言，2022 年人感染猴痘（human monkeypox，HMPX）疫情中，病例的臨床表現與既往報告也存在相當大的差異，這增強了此次疫情“非同尋常”的特點。

近期，越來越多的數據揭示了2022 年HMPX病例不尋常的臨床表現［2-3］。世界衛生組織報告此次疫情中，多數病例沒有“發熱、腫大淋巴結，繼之以離心性皮疹”的典型臨床表現，而呈不典型表現，包括：很少甚至僅有單個皮膚病變；有些病例缺乏皮膚病變，表現為肛門疼痛和出血；有生殖器或會陰/肛周區病變，但無擴散；皮膚病變發展不同步；皮膚病變先于發熱、不適和其他全身癥狀（無前驅期）［4］。單一的生殖器病變、口腔或肛門黏膜病灶是新的HMPX 表現形式，有必要增加到HMPX 的臨床描述中，有利于及時識別病例和阻止傳播［5］。

Petersen等［6］指出，有關HMPX的大多數知識都是從既往被動的間斷監測病例和疫情總結中獲得，實際上總體認知尚不夠準確。迄今為止，還不能確定我們是否已經觀察到所有HMPX 的臨床表現類型。從已發表文獻來看，HMPX病例皮疹和淋巴結腫大的數量、分布、性質及發熱、乏力、頭痛、背痛、肌痛等全身癥狀的突出表現，以及上述癥狀和體征病程演變關系，不同疫情之間都可能存在著明顯的差異。Karem 等［7］對2003 年美國HMPX 病例及其密切接觸者的血清學研究還證明，在接種過和未接種過痘苗的個體中都存在無癥狀的HMPX 感染。2022 年疫情中，9 626 例患者中有8例表現為無癥狀［8］。

臨床各科醫生都要重視HMPX 臨床表現的多樣性。在目前分科實踐的模式下，患者因為個體表現的特征，就診的科室絕不會只限于感染科、皮膚科或性病門診。

以下是對應的英文翻譯。

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.