紋身店的 MPXV 傳播
資料來源：N engl j med nejm.org / 財團法人台灣紅絲帶基金會編譯
致編輯：2022 年 7 月 6 日至 19 日，共有 21 人感染了猴痘（最近更名為 mpox）病毒（MPXV），該病毒很可能是透過穿孔或紋身在西班牙加的斯的同一家店內傳播。在此期間，紋身店的 58 名顧客中有 21 名 (36%) 被感染。
在 21 名感染患者中，14 名（67%）為女性，9 名（43%）未滿 18 歲。患者的中位年齡為 26 歲（四分位間距，16 至 38 歲）。 患者近期沒有高危性行為史（例如，沒有避孕屏障方法的性行為或與多個伴侶發生性行為），沒有到 mpox 流行地區旅行，也沒有與 MPXV 感染者密切接觸。
臨床特徵始於疼痛性區域性炎性淋巴結腫大，穿孔或紋身後中位時間為 7 天（四分位距，6 至 9 天）。 所有患者隨後在大約第 9 天（四分位間距，7 至 11）出現局部皮膚炎症。體格檢查顯示穿孔或紋身區域有皮膚壞死，周圍有臍狀膿皰，下面有水腫和紅斑（圖 1）。 隨後，14 例患者出現全身性皮疹，在軀幹、頭部和四肢的紅斑上出現散在的紅斑丘疹和非叢生的臍狀膿皰。膿皰滲出物的聚合酶鏈反應檢測證實了診斷。
首例病例於 7 月 19 日確診。衛生當局接到通知，紋身店於次日關閉並接受調查。在接受測試的客廳中的 16 件與穿孔或紋身相關的物品中，有 15 件呈猴痘病毒陽性。在接下來的 21 天內，每天都對患者、患者的密切接觸者以及紋身店的其他 37 名顧客進行追踪。檢測到患者母親的二次傳播。沒有發生猴痘病毒感染的嚴重併發症，也沒有感染患者住院。共有23名密切接觸者接種了疫苗。Mpox 沒有在任何客廳工作人員中發展，指標病例仍然未知。
目前的 mpox 疫情已於 2022 年在國際範圍內蔓延，引起了全世界的關注。我們描述了可能透過穿孔和紋身直接接種而發生的 MPXV 傳播病例；其他痘病毒（如傳染性軟疣）也觀察到了這種傳播。在臨床上，我們的患者類似於透過人畜共通侵入性接觸而感染的患者。值得注意的是，我們的患者在發病時觀察到區域淋巴結腫大。迄今為止，猴痘病毒的性傳播是最常見的傳播方式，男男性行為者受到的影響尤為嚴重。相較之下，我們報告中的病例主要涉及女性患者。猴痘病毒可能會發展出新的傳播網絡，隨著疾病的流行病學邏輯發生變化。
圖 1。 穿孔和紋身部位的軟骨膜炎和皮膚炎症。 在接受過穿孔或紋身並感染了 mpox 病毒 (MPXV) 的患者的照片中可以看到穿孔或紋身區域的皮膚壞死以及周圍的臍狀膿皰以及下面的水腫和紅斑斑塊（圖片 A 到 D） ). 丘疹膿皰皮疹 (Papulopus tules) 呈簇狀出現，有時呈扇形邊緣，讓人聯想到皰疹病毒感染。 然而，與皰疹病變不同，這些膿皰的內容物是實性的（假性膿皰，pseudopustules）。 圖 E 顯示了散在的紅斑丘疹和紅斑上的非簇狀臍狀膿皰的皮膚播散性病變。通常被描述為單形的播散性病變可能出現在不同的進化階段，呈現出「星空」外觀。圖 F 顯示了紅斑上非叢生的臍狀膿皰的更多細節。
Myriam Viedma Martinez，醫學博士； Francisco R. Dominguez Tosso，醫學博士；David Jimenez Gallo，醫學博士，哲學博士 Hospital Universitario Puerta del Mar Cadiz，西班牙 myriamdermatologiacadiz@gmail.com Jesus Garcia Palacios，醫學博士； Andaluz Health Services, Bahia de Cádiz–La Janda District 西班牙加的斯
Laura Riera Tur，醫學博士 Natalia Montiel Quezel，醫學博士，哲學博士 Mario Linares Barrios，醫學博士，哲學博士 Universitario Puerta del Mar Cadiz 醫院，西班牙
作者提供的披露表與這封信的全文可在 NEJM.org 上獲取。
這封信於 2022 年 12 月 14 日在 NEJM.org 上發表。
MPXV Transmission at a Tattoo Parlor
N engl j med nejm.org
To the Editor: From July 6 to 19, 2022, a total of 21 persons were infected by monkeypox (recently renamed mpox) virus (MPXV) that was likely to have been transmitted by means of piercing or tattooing at the same parlor in Cadiz, Spain. During this period, 21 of 58 customers (36%) at the tattoo parlor became infected.
Of the 21 infected patients, 14 (67%) were female and 9 (43%) were younger than 18 years of age. The median age of the patients was 26 years (interquartile range, 16 to 38). The patients had no history of recent high-risk sexual activity (e.g., sex without a barrier method of contraception or with multiple partners), travel to areas where mpox is endemic, or close contact with MPXV-infected persons.
Clinical features started with painful regional inflammatory lymphadenopathy, with onset a median of 7 days (interquartile range, 6 to 9) after the piercing or tattooing. All the patients subsequently had local cutaneous inflammation on approximately day 9 (interquartile range, 7 to 11). Physical examination showed cutaneous necrosis in the area of the piercing or tattoo and surrounding umbilicated pustules with an underlying edematous and erythematous plaque (Fig. 1). Subsequently, 14 patients had a systemic cutaneous rash with scattered erythematous papules and nonclustered umbilicated pustules over erythematous macules on the trunk, head, and limbs. Polymerase-chain-reaction testing of pustule exudates confirmed the diagnoses.
The first case was diagnosed on July 19. Health authorities were notified, and the tattoo parlor was closed and investigated on the following day. Of the 16 piercing- or tattooing-related items in the parlor that were tested, 15 were positive for MPXV. The patients, close contacts of the patients, and the other 37 customers of the tattoo parlor were traced daily for the next 21 days. A secondary transmission in a patient’s mother was detected. No severe complications of MPXV infection developed, and no infected patients were hospitalized. A total of 23 close contacts were vaccinated. Mpox did not develop in any of the parlor staff, and the index case remains unknown.
The current mpox outbreak has spread internationally in 2022, sparking concern worldwide. We describe cases of MPXV transmission that were likely to have occurred by means of direct inoculation from piercing and tattooing; such transmission has been observed with other poxviruses, such as Molluscum contagiosum. Clinically, our patients resembled patients who were infected by means of zoonotic invasive exposure. It is notable that regional lymphadenopathy at disease onset was observed in our patients. To date, sexual transmission of MPXV has been the most common mode of transmission, with men who have sex with men being disproportionately affected.4,5 In contrast, the cases in our report mostly involved female patients. MPXV may develop new networks of transmission, with epidemiologic changes of the disease.
Figure 1. Perichondritis and Cutaneous Inflammation on Piercings and Tattoo Site. Cutaneous necrosis at the area of the piercing or tat too and surrounding umbilicated pustules with an un derlying edematous and erythematous plaque are seen in photographs of patients who had undergone piercing or tattooing and become infected with the mpox virus (MPXV) (Panels A through D). Papulopus tules appeared in clusters, sometimes with scalloped edges reminiscent of herpesvirus infections. However, unlike herpes lesions, these pustules were solid in content (pseudopustules). Panel E shows skin-dissem inated lesions of scattered erythematous papules and nonclustered umbilicated pustules over erythematous macules. Disseminated lesions, which are usually de scribed as monomorphic, may appear in different evo lutionary stages, giving a “starry sky” appearance. Panel F shows more detail of a nonclustered umbili cated pustule over an erythematous macule.
Myriam Viedma Martinez, M.D. ; Francisco R. Dominguez Tosso, M.D. ;David Jimenez Gallo, M.D., Ph.D. Hospital Universitario Puerta del Mar Cadiz, Spain myriamdermatologiacadiz@gmail.com Jesus Garcia Palacios, M.D. ; Andaluz Health Services, Bahia de Cádiz–La Janda District Cadiz, Spain
Laura Riera Tur, M.D. Natalia Montiel Quezel, M.D., Ph.D. Mario Linares Barrios, M.D., Ph.D. Hospital Universitario Puerta del Mar Cadiz, Spain
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
This letter was published on December 14, 2022, at NEJM.org.