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MPXV Transmission at a Tattoo Parlor
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Jan 5 2023
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 (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). During this period, 21 of 58 customers (36%) at the tattoo parlor became infected (Fig. S1).
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 (Figure 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 (Table S2). 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.1 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.2 Clinically, our patients resembled patients who were infected by means of zoonotic invasive exposure.3 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.

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