Monkeypox-Associated Central Nervous System Disease: A Case Series and Review

Kelli M. Money, T. Allen Barnett, Samuel Rapaka, Rebecca Osborn, Takashi Kitani, Daniel Fuguet, Faria Amjad, Jeffrey R. Clark, Debanjana Chakravarty, Matthew J. Copeland, Justin M. Honce, Princy N. Kumar, Rebecca N. Kumar, Fady Mousa-Ibrahim, Bilaal Sirdar, Rafal Sobota, Mengxuan Tang, Maureen K. Bolon, Eric J. Russell, Michael WilsonCarlo Tornatore, Ayush Batra, Kenneth L. Tyler, Daniel M. Pastula

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Objective: Monkeypox virus (MPXV) disease has been declared a public health emergency by the World Health Organization, creating an urgent need for neurologists to be able to recognize, diagnosis, and treat MPXV-associated neurologic disease. Methods: Three cases of MPXV-associated central nervous system (CNS) disease occurring during the 2022 outbreak, and their associated imaging findings are presented, with 2 cases previously published in a limited capacity in a public health bulletin. Results: Three previously healthy immunocompetent gay men in their 30s developed a febrile illness followed by progressive neurologic symptoms with presence of a vesiculopustular rash. MPXV nucleic acid was detected by polymerase chain reaction (PCR) from skin lesions of 2 patients, with the third patient having indeterminate testing but an epidemiologic link to a confirmed MPXV disease case. Cerebrospinal fluid demonstrated a lymphocytic pleocytosis, elevated protein, and negative MPXV-specific PCR. In 2 patients, magnetic resonance imaging of the brain and spine demonstrated partially enhancing, longitudinally extensive central spinal cord lesions with multifocal subcortical, basal ganglia, thalamic, cerebellar, and/or brainstem lesions. The third patient had thalamic and basal ganglia lesions. All patients received 14 days of tecovirimat, and 2 patients also received multiple forms of immunotherapy, including intravenous immunoglobulin, pulsed high-dose steroids, plasmapheresis, and/or rituximab. Good neurologic recovery was observed in all cases. Interpretation: MPXV can be associated with CNS disease. It is unclear whether this is from a parainfectious immune-mediated injury or direct CNS viral invasion. ANN NEUROL 2023;93:893–905.

Original languageEnglish (US)
Pages (from-to)893-905
Number of pages13
JournalAnnals of Neurology
Issue number5
StatePublished - May 2023
Externally publishedYes

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Publisher Copyright:
© 2023 The Authors. Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.


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