Mpox clinical features and varicella-zoster virus coinfection in the Democratic Republic of Congo: a systematic review and meta-analysis (1970-2024)

Background Monkeypox (Mpox) remains endemic in the Democratic Republic of Congo (DRC), with inc. Despite five decades of outbreaks, gaps persist in understanding clinical patterns and coinfections with varicella-zoster virus (VZV) and HIV in this high-burden setting. Methods We conducted a systematic review and meta-analysis (1970-2024) of Mpox cases in the DRC, extracting data from PubMed, ScienceDirect, and Google Scholar. Pooled prevalence rates were calculated using fixed and random-effects models, with subgroup analyses by time period, region, setting, study design and participant characteristics. Results Among 1,841 confirmed Mpox cases, VZV coinfection was 9.69% (95% CI: 1.33-18.06; n = 8), with higher rates in Kivu (33.33%) versus Equateur (11.10%). The VZV pooled prevalence rate among 64131 suspected Mpox cases was 16.73% (95% CI: 5.36-28.10; n = 8), with I2 = 99.4% (p ˂ 0.001). HIV coinfection was low (0.52%, 95% CI: 0.18-0.87) but elevated in South Kivu (1.64%). Among confirmed cases, rash (99.97%), painful lesions (78.17%), and Malaise (77.14%) dominated clinical presentation and underscored their diagnostic importance in the case definition. A similar clinical pattern of Mpox was observed among suspected cases, featuring a near-universal presentation of rash (99.43%) and fever (98.91%). Heterogeneity was high (I2 > 90%) for most outcomes. Conclusion Mpox in the DRC presents with consistent rash-centered symptomatology but high VZV coinfection rates complicate diagnosis. The low HIV coinfection suggests distinct transmission dynamics from global outbreaks. Findings underscore the need for integrated VZV/Mpox diagnostics and context-specific surveillance in endemic regions.