Archives of Academic Emergency Medicine. 2022; 10(1): e67 LE T T E R TO ED I TO R Is Monkeypox a Concern in Multiple Sclerosis Patients? A Letter to Editor Elnaz Asadollahzadeh1, Fereshteh Ghadiri1, Zahra Ebadi1, Abdorreza Naser Moghadasi1∗ 1. Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Received: June 2022; Accepted: July 2022; Published online: 18 August 2022 Cite this article as: Asadollahzadeh E, Ghadiri F, Ebadi Z, Naser Moghadasi A. Is Monkeypox a Concern in Multiple Sclerosis Patients? A Letter to Editor. Arch Acad Emerg Med. 2022; 10(1): e67. https://doi.org/10.22037/aaem.v10i1.1729. Dear editor: Individuals with autoimmune conditions have been charac- terized as the population very much prone to illness. This is because of the way various diseases impact their immune system, and because immunosuppressant medications were employed to cure the majority of these ailments (1). By weak- ening the immune system, these drugs allow the control of many autoimmune disorders such as multiple sclerosis. Pa- tients with multiple sclerosis who use these drugs are in dan- ger of developing a weak immune system and a wide range of infectious diseases such as herpesvirus infections (2). Viral, bacterial, and fungal infections can cause MS exacerbations (3). Monkeypox, a virus that resembles smallpox, was first found in captive primates in 1958 and in individuals in the Repub- lic of Congo in 1970 (4). Monkeypox virus is an evolving zoonotic orthopoxvirus (OPXV ) that can cause a severe and transmittable human disease, potentially posing threats to public health (5). The most prevailing reason for the emer- gence of monkeypox cases has been diminishing immunity. There are currently no specific treatments for monkeypox disease, yet outbreaks can be managed (6). Those with a compromised immune system, may be at a higher risk for complications if infected, in spite of vaccination (7). Peo- ple with weakened immune systems are much more suscep- tible to lethal forms of the disease. When compared to other people, patients with autoimmune conditions, such as MS, have a 3-20-fold greater risk of catching smallpox (8). In the meantime, people with extreme immunodeficiency should not be analyzed or clinically treated for symptoms suggestive of monkeypox (9). The authors’ examination of the literature on past and ∗Corresponding Author: Abdorreza Naser Moghadasi; Multiple Sclerosis Re- search Center, Sina Hospital, Hassan Abad square, Tehran, Iran. E-mail: ab- dorrezamoghadasi@gmail.com, Tel: +98 21 66348571, Fax: +98 21 66348571, ORCID: https://orcid.org/0000-0002-8598-0911. present experiences with monkeypox in multiple sclerosis patients was spurred by the recent epidemic of monkeypox. While the consequences of monkeypox in patients with MS are unknown, the danger of contracting this lethal illness sur- passes the chance of MS relapse. There is compelling evi- dence that an infectious episode increases the chance of MS aggravation. As a result, it is preferable to keep track of MS patients on a frequent basis in order to avoid problems. Evi- dence backs up 1) methods to reduce the risk of contracting infectious diseases that might cause MS exacerbations, and 2) the safety of vaccinations in MS patients. The mandated precautions should be observed in MS pa- tients to avoid this infection. Despite the fact that this virus is conveyed through contact with suspected cases, people on immunosuppressive medicines are still at risk of the ill- ness. The high rate of infections when taking immune- suppressants highlights the significance of carefully weighing the risks and benefits of various immune-modifying medica- tions. Adverse events due to infections were reduced in pa- tients taking immunosuppressant medications for MS after a risk mitigation program that included infectious disease con- sulting and standardized screening and preventive measures. Declarations Acknowledgments None. Authors’ contributions Elnaz Asadollahzadeh and Abdorreza Naser Moghadasi: Lit- erature search, manuscript preparation, manuscript editing and manuscript review. Fereshteh Ghadiri and Zahra Ebadi: manuscript preparation and manuscript editing. All authors read and approved final version of manuscript. Funding and supports None. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem E. Asadollahzadeh et al. 2 Conflict of interest The Authors declare that they have no conflict of interest. References 1. ASSESSMENT RR. Monkeypox multi-country outbreak. 2022. http://www.sepexpal.org/wp- content/uploads/2022/05/23-mayo.-ECDC.-Monkeypox- multi-country-outbreak.pdf 2. Lebrun C, Vukusic S. Immunization and multiple sclero- sis: recommendations from the French multiple sclerosis society. Mult Scler Relat Disord. 2019;31:173-88. 3. Castelo-Branco A, Chiesa F, Conte S, Bengtsson C, Lee S, Minton N, et al. Infections in patients with multiple scle- rosis: a national cohort study in Sweden. Mult Scler Relat Disord. 2020;45:102420. 4. Rezza G. Emergence of human monkeypox in west Africa. Lancet Infect Dis. 2019;19(8):797-9. 5. Yinka-Ogunleye A, Aruna O, Ogoina D, Aworabhi N, Eteng W, Badaru S, et al. Reemergence of human monkeypox in Nigeria, 2017. Emerg Infect Dis. 2018;24(6):1149. 6. Vaughan A, Aarons E, Astbury J, Balasegaram S, Beadsworth M, Beck CR, et al. Two cases of monkey- pox imported to the United Kingdom, September 2018. Euro Surveill. 2018;23(38):1800509. 7. Rao AK, Petersen BW, Whitehill F, Razeq JH, Isaacs SN, Merchlinsky MJ, et al. Use of JYNNEOS (Small- pox and Monkeypox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occu- pational Exposure to Orthopoxviruses: Recommenda- tions of the Advisory Committee on Immunization Prac- tices—United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(22):734. 8. Bisanzio D, Reithinger R. Keep Calm and Carry On: Pro- jected Case Burden and Duration of the 2022 Monkeypox Outbreak in Non-endemic Countries. medRxiv. 2022. 9. Mahase E. Monkeypox: Healthcare workers will be offered smallpox vaccine as UK buys 20 000 doses. BMJ.2022;377:o1379. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Declarations References