Clinical Spectrum and Outcomes of Pediatric Mpox during the Sindh Outbreak: A Four-Case Series from Sukkur, Sindh, Pakistan

Abstract

Background: Mpox is a viral zoonotic disease caused by monkeypox virus (MPXV), with continuing international transmission and evolving epidemiology. Although pediatric cases are less frequently reported than adult cases, neonates and young infants may be at increased risk of severe disease. Published information regarding pediatric mpox from Pakistan remains limited.
Case Presentation: We describe four PCR-confirmed pediatric mpox cases managed at a tertiary pediatric referral hospital in Sukkur during the 2026 Sindh mpox outbreak. Case 1 was a 9-year-old boy with an atypical purpuric eruption predominantly involving the lower extremities, accompanied by abdominal pain and vomiting, clinically mimicking IgA vasculitis. Case 2 was a 21-day-old neonate with disseminated vesiculopustular lesions, oral involvement, seizures, poor feeding, and respiratory distress who died following progressive clinical deterioration. Case 3 was a 2-month-old infant with extensive disseminated and partly necrotic cutaneous lesions, oral involvement, feeding difficulty, and severe respiratory distress who also died. Case 4 was a 35-day-old infant with generalized vesiculopustular lesions and a reported household contact with confirmed mpox who recovered with supportive management. MPXV infection was confirmed by PCR from cutaneous lesion specimens in all four patients. Patient-level viral clade determination was not performed.
Conclusion: Pediatric mpox may present across a broad clinical spectrum, ranging from atypical localized purpuric eruptions to severe disseminated disease in neonates and young infants. The two fatal cases highlight the potential vulnerability of young infants, although the precise mechanisms of death could not be definitively established. Early recognition, laboratory confirmation, isolation, supportive care, and rigorous infection-prevention measures are essential during outbreaks.