An internal inflammation of the anus that can lead to severe pain has been linked to monkeypox virus infection. Called proctitis, it can also cause tenesmus (constant urge to have a bowel movement, even if it doesn’t happen) and bleeding in the rectum. In some cases, medication is needed to relieve the pain of inflammation. Proctitis affects the anal canal and rectum, located at the end of the digestive tract. The problem appears for different reasons, mainly sexually transmitted infections (STIs). However, one of the more recent causes of proctitis is monkeypox.
A study, published last Monday (8) in the journal The Lancet, observed symptoms and complications caused by monkeypox in 181 Spanish patients. Among them, about 25% registered proctitis. Most of these had a history of receptive anal intercourse. The data reaffirms the hypothesis that the appearance of proctitis due to monkeypox involves scenarios in which the infection occurs in intimate contact during sex.
José Ricardo Coutinho, a member of the SBCP (Brazilian Society of Coloproctology), agrees with this explanation, not least because most transmissions are occurring through sexual contact. “It is believed that it is because of the way this disease is being transmitted”, says Coutinho, who did not sign the new study.
Through intimate and prolonged contact during anal sex, the virus would have a gateway to infect the human organism. Therefore, complications would appear early in this region of the body, as in the case of proctitis. “I think it’s the way the infection occurs”, summarizes the doctor.
For him, the appearance of proctitis is more related to the practice of anal sex in men who have sex with other men – the group with the highest number of cases of monkeypox. In the recently published research, the data is also pointed out: of the 181 participants, 162 were men who had sex with other men. Therefore, Coutinho says it is necessary to alert this community to be aware of the complication.
However, monkeypox infection does not only occur during sex and does not affect only these men. Transmission occurs mainly through direct contact with the lesions that patients have on the skin. Examples that the disease can affect anyone are the cases already recorded in children and adults without a history of recent sexual intercourse.
The point is also a reminder of the need to avoid stigma against the population of men who have sex with men, an aspect already pointed out by health entities such as the WHO (World Health Organization) and Unaids (Joint United Nations Program on HIV/AIDS).
Difficulties in diagnosis Proctitis due to monkeypox can delay the diagnosis of the disease, says Coutinho. According to him, rectal inflammation is usually associated with STIs, such as chlamydia and gonorrhea.
The scenario can make both patients and health professionals suspect other diseases to explain the emergence of anal inflammation rather than assuming that it would be a case of monkeypox. For Coutinho, this raises fears of monkeypox cases that could be underreported.
A similar case has already been reported in an article in the American magazine The New Yorker. The report followed a man who presented internal lesions in the anus and had difficulty performing the test for the monkeypox virus because he did not show the wounds on the skin. In the end, the patient was able to take the exam and had indeed been infected by the pathogen.
In Brazil, proctitis is already considered as a manifestation that indicates suspicion for monkeypox. According to the national contingency plan for the disease of the Ministry of Health, the presentation of proctitis already puts the person as a suspected case of monkeypox, even if he does not present lesions in other parts of the body.
Differences from the current outbreak
The development of proctitis is one among other presentations of monkeypox that were not normally seen in previous cases.
A particularity of the current outbreak is the concentration of lesions typical of monkeypox in the genital and perianal region. In the recently published Spanish study, about 78% of the patients had this condition.
The hypothesis to explain this difference is the same in cases of proctitis: as most infections are associated with intimate contact during sex, the concentration of wounds in the genital and anal region occurs more frequently.
Another difference from the new diagnoses is the appearance of subtle lesions that often generate confusion for other diseases. One patient, for example, even thought that the wound caused by the infection was a pimple. This clinical picture, as in the case of proctitis, can delay the diagnosis of monkeypox and worries specialists. (Samuel Fernandes/Folhapress)
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