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Emergency: requires immediate attention
Monkeypox in Adult
Other Resources UpToDate PubMed
Emergency: requires immediate attention

Monkeypox in Adult

Contributors: Paritosh Prasad MD, Edith Lederman MD, Susan Burgin MD
Other Resources UpToDate PubMed

Synopsis

Updated November 4, 2022. 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 monkeypox (MPX) to be a public health emergency of international concern on July 23, 2022. MPX was declared a public health emergency in the United States on August 4, 2022.

As of November 4, 2022, the CDC reports 78 000 confirmed cases of MPX globally in over 100 locations, the vast majority of which (> 90%) have not historically reported MPX infections, and more than 28 600 confirmed cases across the United States, including 8 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 monkeypox – regardless of age, sexual orientation, or gender identity – is at risk for contracting MPX.

Per a CDC report spanning May 17 through September 24, 2022, MPX 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 MPX 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 MPX 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 MPX 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.
Community transmission seems to be occurring through close contact, ie, direct contact with skin lesions or bodily fluids, or indirect contact via contaminated clothing or linens, or exposure to large respiratory droplets.

Anyone who has had close physical contact with someone with MPX is at risk of contracting the virus.

Clinical features:

The incubation period of MPX 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 MPX 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.
In the 2022 outbreak, MPX may present in a form that can be very subtle and easily mistaken for many other conditions such as primary and secondary syphilis, genital herpes simplex virus (HSV), and chancroid, among others. This presentation has been described across many parts of Europe, the United Kingdom, Canada, and the United States.

Transmission:
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 MPX 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 MPX 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%).

About MPX
MPX is a rare zoonotic Orthopoxvirus infection that is clinically similar to smallpox.

There are 2 clades of MPX, 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, MPX 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 MPX 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 Monkeypox virus (MPXV) 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 MPXV was needed.

The first documented outbreak of MPX 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.

Codes

ICD10CM:
B04 – Monkeypox

SNOMEDCT:
359814004 – Monkeypox

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Last Reviewed:11/02/2022
Last Updated:11/13/2022
Copyright © 2022 VisualDx®. All rights reserved.
Emergency: requires immediate attention
Monkeypox in Adult
A medical illustration showing key findings of Monkeypox : Chills, Fever, Headache, Central Africa, Lymphadenopathy, Myalgia, Umbilicated vesicles
Clinical image of Monkeypox - imageId=1589825. Click to open in gallery.  caption: '2003 outbreak: Numerous large pustules, some single and some clustered, some crusted and one ulcerated, on the hand and thumb.'
2003 outbreak: Numerous large pustules, some single and some clustered, some crusted and one ulcerated, on the hand and thumb.
Copyright © 2022 VisualDx®. All rights reserved.