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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We recently published a mpox concise review focused on the new features of dermatological lesions that were observed during the 2022 outbreak&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In response to this publication&#44; Kleebayoon and Wiwanitkit<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> submitted an interesting letter pointing out the existence of mpox cases where diagnosis is challenging due to atypical or initially absent skin lesions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree that a significant percentage of patients do not initially present mucocutaneous lesions&#46; Large 2022 case series reported 36&#37;&#8210;61&#46;5&#37; of patients develop unspecific systemic prodromic manifestations &#40;fever&#44; malaise&#44; lymphadenopathy&#44; headache&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Accurate diagnosis prior to the presence of mucocutaneous lesions is difficult&#46; However&#44; it is noteworthy that in this outbreak the absence of systemic symptoms or their appearance after the cutaneous manifestations was more frequent compared to previous outbreaks of classical mpox&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although typical skin lesions consist of pseudopustules which may be followed by a second exanthematous phase&#44; other more infrequent skin lesions have been described&#46; For example&#44; some patients develop a finger whitlow&#46; In a 2022 study&#44; mpox whitlows&#44; together with mucosa and single skin lesions led to clinical misdiagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Mucosal involvement is not uncommon&#44; but symptoms are unspecific&#44; mimicking other possible diagnoses&#46; Oropharyngeal manifestations include oral and tonsillar ulcers&#44; epiglottitis&#44; and pharyngitis&#44; leading to odynophagia and dysphagia&#46; The anorectal mucosa can be affected with ulcerations or proctitis&#44; which produce symptoms such as pain&#44; bleeding&#44; tenesmus&#44; or diarrhea&#46; Conjunctival mucosa involvement is more infrequent but can lead to keratitis and vision loss&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As Kleebayoon and Wiwanitkit<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> claim&#44; Polymerase Chain Reaction &#40;PCR&#41; testing may present false positives and negatives&#46; Nevertheless&#44; these limitations are inherent to any diagnostic test&#46; We&#44; therefore&#44; agree that sampling and analysis should be repeated in doubtful cases&#46; Atypical cases may even require a skin biopsy to make an accurate diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; to date&#44; the PCR test is the main confirmatory diagnostic method&#46; Skin lesions have the highest diagnostic yield &#40;sensitivity 91&#37;&#8211;100&#37;&#41; but other samples &#40;oral&#44; nasopharyngeal&#44; or rectal swab&#41; can also be collected and assess laboratory diagnosis in cases without skin lesions&#46; On the contrary&#44; there is no clear evidence about the diagnostic reliability of blood&#44; urine&#44; and feces PCR testing&#46; Mpox rapid antigen tests have also been developed&#46; Their practical utility is unclear because they have lower sensitivity than PCR tests&#46; However&#44; they could be helpful if PCR testing is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In order to make mpox diagnosis easier for clinicians&#44; several artificial intelligence tools have been developed&#46; They recognize images of mpox typical skin lesions&#44; differentiating them from images of other diseases&#46; Most of them achieved high accuracy&#46; Notwithstanding&#44; they have not been tested in real life and some privacy issues remain to be solved&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Elena Luc&#237;a Pinto-Pulido&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; preparation and writing of the manuscript&#59; study conception and planning&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Miriam Fern&#225;ndez-Parrado&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; manuscript critical review&#59; study conception and planning&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Francisco Jos&#233; Rodr&#237;guez-Cuadrado&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; manuscript critical review&#59; study conception and planning&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Atypical clinical features of mpox (monkeypox): a diagnostic challenge - Reply
Elena Lucía Pinto-Pulidoa,
Corresponding author
elucia.pinto95@gmail.com

Corresponding author.
, Miriam Fernández-Parradob, Francisco José Rodríguez-Cuadradoc
a Department of Dermatology, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Madrid, Spain
b Department of Dermatology, Hospital Universitario de Navarra, Pamplona, Spain
c Department of Dermatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We recently published a mpox concise review focused on the new features of dermatological lesions that were observed during the 2022 outbreak&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In response to this publication&#44; Kleebayoon and Wiwanitkit<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> submitted an interesting letter pointing out the existence of mpox cases where diagnosis is challenging due to atypical or initially absent skin lesions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree that a significant percentage of patients do not initially present mucocutaneous lesions&#46; Large 2022 case series reported 36&#37;&#8210;61&#46;5&#37; of patients develop unspecific systemic prodromic manifestations &#40;fever&#44; malaise&#44; lymphadenopathy&#44; headache&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Accurate diagnosis prior to the presence of mucocutaneous lesions is difficult&#46; However&#44; it is noteworthy that in this outbreak the absence of systemic symptoms or their appearance after the cutaneous manifestations was more frequent compared to previous outbreaks of classical mpox&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although typical skin lesions consist of pseudopustules which may be followed by a second exanthematous phase&#44; other more infrequent skin lesions have been described&#46; For example&#44; some patients develop a finger whitlow&#46; In a 2022 study&#44; mpox whitlows&#44; together with mucosa and single skin lesions led to clinical misdiagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Mucosal involvement is not uncommon&#44; but symptoms are unspecific&#44; mimicking other possible diagnoses&#46; Oropharyngeal manifestations include oral and tonsillar ulcers&#44; epiglottitis&#44; and pharyngitis&#44; leading to odynophagia and dysphagia&#46; The anorectal mucosa can be affected with ulcerations or proctitis&#44; which produce symptoms such as pain&#44; bleeding&#44; tenesmus&#44; or diarrhea&#46; Conjunctival mucosa involvement is more infrequent but can lead to keratitis and vision loss&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As Kleebayoon and Wiwanitkit<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> claim&#44; Polymerase Chain Reaction &#40;PCR&#41; testing may present false positives and negatives&#46; Nevertheless&#44; these limitations are inherent to any diagnostic test&#46; We&#44; therefore&#44; agree that sampling and analysis should be repeated in doubtful cases&#46; Atypical cases may even require a skin biopsy to make an accurate diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; to date&#44; the PCR test is the main confirmatory diagnostic method&#46; Skin lesions have the highest diagnostic yield &#40;sensitivity 91&#37;&#8211;100&#37;&#41; but other samples &#40;oral&#44; nasopharyngeal&#44; or rectal swab&#41; can also be collected and assess laboratory diagnosis in cases without skin lesions&#46; On the contrary&#44; there is no clear evidence about the diagnostic reliability of blood&#44; urine&#44; and feces PCR testing&#46; Mpox rapid antigen tests have also been developed&#46; Their practical utility is unclear because they have lower sensitivity than PCR tests&#46; However&#44; they could be helpful if PCR testing is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In order to make mpox diagnosis easier for clinicians&#44; several artificial intelligence tools have been developed&#46; They recognize images of mpox typical skin lesions&#44; differentiating them from images of other diseases&#46; Most of them achieved high accuracy&#46; Notwithstanding&#44; they have not been tested in real life and some privacy issues remain to be solved&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Elena Luc&#237;a Pinto-Pulido&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; preparation and writing of the manuscript&#59; study conception and planning&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Miriam Fern&#225;ndez-Parrado&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; manuscript critical review&#59; study conception and planning&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Francisco Jos&#233; Rodr&#237;guez-Cuadrado&#58; Approval of the final version of the manuscript&#59; critical literature review&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; manuscript critical review&#59; study conception and planning&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03650596
Original language: English
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