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Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series

BMJ 2022; 378 doi: (Published 28 July 2022) Cite this as: BMJ 2022;378:e072410

Linked Editorial

The changing face of monkeypox

  1. Aatish Patel, infectious diseases registrar,
  2. Julia Bilinska, sexual health and HIV registrar,
  3. Jerry C H Tam, infectious diseases registrar,
  4. Dayana Da Silva Fontoura, infectious diseases registrar,
  5. Claire Y Mason, infectious diseases registrar,
  6. Anna Daunt, infectious diseases registrar,
  7. Luke B Snell, infectious diseases registrar,
  8. Jamie Murphy, infectious diseases registrar,
  9. Jack Potter, charge nurse,
  10. Cecilia Tuudah, infection prevention and control nurse,
  11. Rohan Sundramoorthi, core medical trainee,
  12. Movin Abeywickrema, clinical fellow,
  13. Caitlin Pley, foundation doctor,
  14. Vasanth Naidu, core medical trainee,
  15. Gaia Nebbia, virology consultant,
  16. Emma Aarons, virology consultant,
  17. Alina Botgros, virology consultant,
  18. Sam T Douthwaite, infectious diseases and, virology consultant,
  19. Claire van Nispen tot Pannerden, infectious diseases consultant,
  20. Helen Winslow, infectious diseases consultant,
  21. Aisling Brown, infectious diseases consultant,
  22. Daniella Chilton, sexual health and HIV consultant,
  23. Achyuta Nori, sexual health and HIV consultant
  1. Guys and St Thomas’ NHS Foundation Trust, London, SE1 7EH, UK
  1. Correspondence to: A Patel Aatish.patel{at}
  • Accepted 22 July 2022


Objective To characterise the clinical features of monkeypox infection in humans.

Design Descriptive case series.

Setting A regional high consequences infectious disease centre with associated primary and secondary care referrals, and affiliated sexual health centres in south London between May and July 2022.

Participants 197 patients with polymerase chain reaction confirmed monkeypox infection.

Results The median age of participants was 38 years. All 197 participants were men, and 196 identified as gay, bisexual, or other men who have sex with men. All presented with mucocutaneous lesions, most commonly on the genitals (n=111 participants, 56.3%) or in the perianal area (n=82, 41.6%). 170 (86.3%) participants reported systemic illness. The most common systemic symptoms were fever (n=122, 61.9%), lymphadenopathy (114, 57.9%), and myalgia (n=62, 31.5%). 102/166 (61.5%) developed systemic features before the onset of mucocutaneous manifestations and 64 (38.5%) after (n=4 unknown). 27 (13.7%) presented exclusively with mucocutaneous manifestations without systemic features. 71 (36.0%) reported rectal pain, 33 (16.8%) sore throat, and 31 (15.7%) penile oedema. 27 (13.7%) had oral lesions and 9 (4.6%) had tonsillar signs. 70/195 (35.9%) participants had concomitant HIV infection. 56 (31.5%) of those screened for sexually transmitted infections had a concomitant sexually transmitted infection. Overall, 20 (10.2%) participants were admitted to hospital for the management of symptoms, most commonly rectal pain and penile swelling.

Conclusions These findings confirm the ongoing unprecedented community transmission of monkeypox virus among gay, bisexual, and other men who have sex with men seen in the UK and many other non-endemic countries. A variable temporal association was observed between mucocutaneous and systemic features, suggesting a new clinical course to the disease. New clinical presentations of monkeypox infection were identified, including rectal pain and penile oedema. These presentations should be included in public health messaging to aid early diagnosis and reduce onward transmission.


  • Contributors: AP, JB, and DDSF conceived this project. AP, JB, JCHT, DDSF, AD, CYM, LBS, JM, JP, CT, RS, MA, CP, and VN collected the data. AP, JB, JCHT, AD, CYM, and LBS were responsible for statistical analyses. AP, JB, JCHT, and DDSF wrote the first draft of the manuscript. AP, JB, JCHT, DDSF, AD, CYM, LBS, JM, JP, CT, RS, MA, CP, VN, and AB edited the manuscript. AN, DC, AB, HW, CVNTP, AB, EA, GN, and SD provided support and advice throughout the process of writing and analysing this study. All authors approved the final version of the manuscript. AN is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: None received.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Patient consent: Obtained.

  • The lead author (AN) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported and that no important aspects of the study have been omitted.

  • Dissemination to participants and related patient and public communities: To disseminate our results, we will share this information within our professional societies and networks at conferences and webinars. We will use social media to share the key messages and produce a plain language summary to be used for wider dissemination to patient advocacy groups, and patient organisations.

  • Provenance and peer review: Commissioned; externally peer reviewed.

Data availability statement

Anonymised data is available on reasonable request.

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