Emergency: requires immediate attention
Mpox in Adult
Alerts and Notices
SynopsisUpdated January 27, 2023. Refer to US Centers for Disease Control and Prevention (CDC) (Information for Clinicians) for the most current information. See Diagnostic Pearls section for the CDC case definitions.
The World Health Organization (WHO) declared mpox (historically, monkeypox) to be a public health emergency of international concern on July 23, 2022. Mpox was declared a public health emergency in the United States on August 4, 2022. The US national public health emergency declaration ended on January 31, 2023.
As of January 25, 2023, the CDC reports 85 146 confirmed cases of mpox globally in over 100 locations, the vast majority of which did not historically report mpox infections, and more than 30 039 confirmed cases across the United States, including 26 deaths. However, the 7-day daily average of new cases has been falling since a peak in August 2022, with cases hitting the lowest level since June.
Transmission continues to occur primarily among men who have sex with men (MSM), but any individual who has been in close, personal contact with someone who has mpox – regardless of age, sexual orientation, or gender identity – is at risk for contracting mpox.
Per a CDC report spanning May 17 through September 24, 2022, mpox virus infections in children and adolescents younger than 18 years of age were rare, representing 0.3% of all US cases; none of the cases resulted in critical illness or death. Children aged 0-12 years typically acquired mpox after skin-to-skin contact with an infected household member during caregiving activities, and adolescents aged 13–17 years were most frequently exposed through male-to-male sexual contact.
Domestic animals, pets, and wildlife in close contact with an infected individual may also be at risk for contracting illness.
Immunocompromised patient considerations: Immunocompromised individuals, particularly people with advanced or inadequately treated HIV, are at risk for severe and prolonged illness and even death. An increasing proportion of cases have been identified among Black and Hispanic / Latino individuals, who are disproportionately affected by HIV.
The 2022 outbreak of mpox is unique in several ways.
- Many cases have no clear connection to the larger clusters of cases and no clear history of associated travel.
- In the 2022 outbreak, it appears mpox is spreading through specific social and sexual networks, particularly among persons who identify as gay, bisexual, or MSM, although it is in no way limited to any specific population.
Anyone who has had close physical contact with someone with mpox is at risk of contracting the virus.
The incubation period of mpox is approximately 12 days (7-14 day range usually, but can be 5-21 days).
The clinical presentation is distinct from prior descriptions of the illness. Notably, anogenital lesions (in some cases painful, in others painless), often without a prodrome, are being observed.
- Many patients have had no associated or preceding febrile illness, fatigue, or other systemic symptoms.
- The eruption that many of these patients develop does not begin on the face, hands, and legs and may not be widespread, nor are the lesions initially numerous. Many patients have presented with a small number of lesions (in some cases 1 or 2) involving the genital or perianal region before the rash spreads to the extremities. These lesions can be, but are not always, quite painful and/or pruritic and may leave scarring.
- The classically described lymphadenopathy associated with mpox does not seem to be a requisite aspect of cases in this outbreak, with some patients having only a single swollen lymph node and some having no lymphadenopathy.
- Some patients present with proctitis or anorectal pain.
- Oropharyngeal symptoms have been reported (including pharyngitis, oral / tonsillar lesions, odynophagia, and epiglottitis) as have conjunctival mucosa lesions.
Human-to-human transmission occurs through close contact, ie, large respiratory droplets, direct contact with skin lesions or bodily fluids, or indirect contact via contaminated clothing or linens. The WHO notes that anyone who has had close physical contact with someone with mpox is at risk of contracting the virus, and there is a high likelihood that further cases with unidentified chains of transmission will be identified. MSM may be at higher risk for infection.
All skin lesions may be infectious. Persons are thought to be infectious starting at the onset of symptoms. Patients should be considered to be infectious until crusts have fallen off and the underlying skin re-epithelialized.
Of note, a UK study of more than 2700 people with confirmed mpox virus between May 6 and August 1, 2022, suggests that presymptomatic transmission (1-4 days before symptoms appear) occurred in around half of all cases (53%).
Mpox is a rare zoonotic Orthopoxvirus infection that is clinically similar to smallpox.
There are 2 clades of mpox, with differing mortality rates. The Central Africa (Congo Basin) clade is both more contagious and more severe with a reported mortality rate of around 10.6%. The West African clade is thought to be less severe with a mortality rate of about 3.6%.
Historically, mpox begins with a prodrome of fever, headache, malaise, backache, lymphadenopathy, chills, nonproductive cough, and arthralgias followed 1-10 days later (usually by day 3) by the development of a papular, vesicular, then pustular eruption on the face, trunk, and extremities. Some patients also experience myalgias, nausea and vomiting, lethargy, sore throat, dyspnea, and sweats. The clinical presentation is similar to but milder than that of smallpox, with the primary difference being that individuals with mpox develop lymphadenopathy, whereas those with smallpox do not. Illness typically lasts 2-4 weeks. Individuals who received smallpox vaccination were reported to develop milder cases.
Before the 2022 outbreak, cases in the United States were primarily limited to laboratory workers, pet shop workers, and veterinarians. There were 2 US cases in 2021 (July and November), both from travelers returning from Nigeria.
In Africa, the disease affects people who have hunted or eaten squirrels and other infected mammals. Animal species susceptible to mpox virus may include nonhuman primates, lagomorphs (rabbits), and some rodents. Predominant person-to-person transmission and prolonged chains of transmission were suspected in 1996 when 71 cases emerged in Katako-Kombe Health Zone, Kasai-Oriental, and Democratic Republic of the Congo, and again in 2003 in the Likouala region of Republic of the Congo. In order to sustain the disease in the human population, it was believed that repeated animal reintroduction of mpox virus was needed.
The first documented outbreak of mpox in the Western Hemisphere was attributed to a shipment of small mammals from Ghana to the United States in 2003. An infected Gambian giant rat from this shipment infected prairie dogs, which in turn transmitted the disease to humans. The prairie dogs were sold by a Milwaukee animal distributor to 2 pet shops in the Milwaukee area and during a pet "swap meet" (pets for sale or exchange) in northern Wisconsin. Patients from this outbreak reported direct or close contact with prairie dogs, most of which were sick. Illness in the prairie dogs was frequently reported as beginning with a blepharoconjunctivitis that was followed by the appearance of nodular lesions in some cases. Some prairie dogs died from the illness while others reportedly recovered. Lesions in the 2003 US outbreak differed from smallpox lesions in that they were not in the same stage of evolution at the same time. In some patients seen in the United States in 2003, early lesions became ulcerated, especially those at animal bite / scratch sites.
B04 – Monkeypox
359814004 – Monkeypox
Differential Diagnosis & PitfallsConditions in the differential diagnosis of genital lesions:
- Genital HSV
- Primary syphilis
- Condyloma lata of secondary syphilis
- Genital aphthous ulcers
- Molluscum contagiosum
- Lymphogranuloma venereum
- Varicella zoster (including chickenpox and disseminated zoster)
- Disseminated HSV
- Eczema herpeticum
- Eczema vaccinatum
- Secondary syphilis
- Alaskapox virus
- Milker’s nodule
- Deer-associated parapoxvirus infection
- Smallpox has been eradicated but remains a bioterrorism threat.
Emergency: requires immediate attention
Mpox in Adult