Maternal and neonatal mpox in Nigeria: a multicentre case series highlighting diagnostic challenges, transmission pathways, and neonatal outcomes

Mpox during pregnancy and the neonatal period remains insufficiently characterised, particularly in endemic African settings. Maternal infection may go unrecognised, while neonatal disease can present early and require prolonged clinical care. We describe three mother–infant pairs managed in southern Nigeria, highlighting maternal recognition, possible transmission pathways, neonatal manifestations, and outcomes. We conducted a retrospective case series of three neonates with laboratory-confirmed mpox managed at three hospitals in southern Nigeria between January and May 2025. Cases were identified during routine clinical care following recognition of neonatal vesiculopustular illness and confirmation of monkeypox virus (MPXV) infection by real-time polymerase chain reaction (RT-PCR) on lesion swabs. Maternal clinical histories, epidemiological information, investigations, management, and outcomes were retrospectively reviewed. Two developed fever and vesiculopustular eruptions in the third trimester, while the third had a brief febrile illness without a recognised rash one day before delivery. Maternal mpox was not recognised before delivery, and none of the women underwent MPXV testing. Two fathers had compatible illnesses following travel outside Rivers State, providing possible additional epidemiological links. All three male neonates developed fever and disseminated vesiculopustular eruptions between days 4 and 9 of life and presented to hospital between days 14 and 16. Neonatal lesion swabs were positive for MPXV by RT-PCR (cycle threshold values, 19.70–21.60), while varicella-zoster virus PCR results were negative. Management was primarily supportive. Tecovirimat was considered but was unavailable for clinical use in Nigeria during the study period. Two neonates recovered completely. The third died at home on day 24 of life following interruption of inpatient care. No post-mortem examination was performed; therefore, the immediate cause of death could not be established. The available evidence did not permit determination of the route of neonatal infection. These cases demonstrate how maternal illness compatible with mpox may remain unrecognised until neonatal disease prompts investigation. Early neonatal presentation, uncertainty about transmission pathways, and challenges sustaining inpatient care highlight important gaps in the recognition and management of mpox at the maternal–newborn interface. Improved clinical suspicion, timely molecular diagnosis, and continuity of care are important priorities in endemic settings.