This transcript has been edited for clarity.
Hello. I’m Paul Auerter from Medscape Infectious Diseases, speaking at Johns Hopkins University School of Medicine.
Monkeypox joins the Legion of Accidental Infectious Diseases, which as an infectious disease consultant we should at least get to know, even if we have never seen it in person, and consider it when the occasion arises.
Monkeypox is a member of the orthopoxvirus family, which is the same as smallpox. It is usually a milder infection that causes many similar diseases that I have never seen clinically, except in a laboratory-generated case of a generalized vaccine in a laboratory technician many years ago, which we diagnosed by electron microscopy.
The current situation with monkeypox is certainly in the news after an outbreak, which at the end of May had at least 260 cases in 19 countries, including many European countries, Argentina and Australia, and also here in the United States, with the highest Few six states report infections, including California, New York, Massachusetts and Florida.
Monkeypox is something we have seen before in the United States. In 2003, there was an outbreak of 71 suspected or confirmed cases that were traced to imports of Gambian giant rats, squirrels or dormice, which spread to prairie dogs, which were subsequently sold as pets. A total of 18 people were hospitalized, but there were no deaths, which certainly suggests a milder disease and a higher death rate from smallpox.
We don’t know much about monkeypox. Although it can live in monkeys and be transmitted this way, the thought is that there is probably a reservoir that is more common in rodents. Acquisition in humans may be from the handling of infected animals or transmission through the skin or mucous membranes, but it is mostly thought to involve large droplets, as it is a large DNA virus and is unlikely to be prone to aerosolization.
The current outbreak here in 2022 is not entirely clear, but there are descriptions in Europe that certain social networks – such as men who have sex with men – can contribute to proliferation. Therefore, the spectrum of, perhaps, sexually transmitted disease (STD) should also be taken into account when evaluating patients.
From onset to onset of symptoms can range from 5 to 21 days, with an average of 1 to 2 weeks. The initial infection is really just a viral prodrome: sometimes a sore throat or lesions, with a rash that usually starts 1-3 days later, initially a viral-type exanthema that is not specific. Flat or macular to papular lesions subsequently become nodular, umbilical or pustucular before crusting. They usually appear on the face and then spread elsewhere on the body, affecting the palms and soles of the feet, which certainly makes it different from other things that may be on your differential, such as chickenpox. You may also have some lymphadenitis.
The differential diagnosis, of course, comes with a primary chickenpox infection, but other measles infections – cowpox or smallpox if there is a bioterrorist event – may need to be considered if you are thinking about measles or sexually transmitted infections (STIs). such as syphilis, herpes simplex virus (HSV) or chancroid.
How to diagnose it, unfortunately, is not easy. Neither the commercial lab nor the lab of your health system will be able to make the diagnosis, so you should contact your local or state health department. Below this video are links to the CDC site for monkeypox, where there is information on collecting samples to obtain direct material for skin lesions for PCR analysis, which may help with confirmation.
In general, the skin is where you see most of this infection. Sometimes, if severe, in patients with fever or more than 100 lesions, especially in children, it can be quite terrible and include pneumonitis. You may also need to consider proctitis if you have sex.
As for treatment, there are no approved treatments and most have been removed from smallpox. There are now two FDA-approved oral drugs that appear to have broad in vitro poxvirus activity, including tecovirimate, which is FDA-approved for smallpox in adults and children, and brincidofovir, a variant of cidofovir that can also be used in humans as young as the age range of newborns.
Other modalities may include immunoglobulin for a vaccine, hoping for cross-reactivity. In terms of prevention, there is a smallpox vaccine available in limited quantities, as well as a modified vaccine that has fewer side effects than the typical vaccine virus that goes by the trade name Jynneos. It is available in very limited quantities, but if you have a case of potential contact, it may be considered or may be considered an adjunct therapy for someone who is infected.
Nothing is well known or described. There are a handful of case reports and a good UK study summarizing the monkeypox experience and some of these newer treatments, but it is uncertain whether they have affected the results or the faster resolution of the disease, given the limitations. number of data points.
These are all things that I think will continue to evolve. Of course, this seems to be the biggest outbreak of monkeypox so far, and it’s worth watching. Many expressed the view that they did not think this would be significant from a public health perspective, but it certainly deserved the observation and attention of infectious disease consultants in assessing certain types of patients.
Thanks a lot for listening. I hope this is useful. Please see the basic information if you need more. Thank you.
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