Don't Monkey Around With Monkeypox

Monkeypox has dominated the news recently. However, the number of cases in non-endemic areas (areas outside of the endemic areas of Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Ghana (identified in animals only), Ivory Coast, Liberia, Nigeria, the Republic of the Congo, Sierra Leone, and South Sudan) is still very low. The numbers are being tracked closely by public health agencies worldwide, like the CDC and WHO. Nevertheless, it is important to understand what the virus is, what it can cause, and how to protect oneself. Monkeypox has been detected in the US in the past without significant spread.

Monkeypox is a virus that is related to smallpox. Due to a successful vaccination campaign, the World Health Assembly declared that smallpox (variola virus) had been eradicated successfully worldwide in 1980, and no subsequent human cases have been confirmed since then. Routine childhood vaccination for smallpox ended in 1972. The smallpox story is a shining example of the success of immunizations. However, there are other poxviruses that are still around and have not been eradicated, but they are not nearly as deadly as the smallpox virus.

The clinical presentation of monkeypox is important to know and is well described on the CDC website. The incubation period (time from infection to symptoms) for monkeypox is usually 7−14 days but can range from 5−21 days.

The illness begins with:

• Fever
• Headache
• Muscle aches
• Backache
• Swollen lymph nodes
• Chills
• Exhaustion

Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a rash, often beginning on the face that spreads to other parts of the body.

Lesions progress through the following stages before falling off:

• Macules
• Papules
• Vesicles
• Pustules
• Scabs

The illness typically lasts for 2−4 weeks. In Africa, monkeypox has been shown to cause death in as many as 1 in 10 persons who contract the disease, but some variants can have a mortality rate of 1 in 100 persons who contract the disease.

The rash is fairly distinctive in that it usually is located on the face, arms, and legs. They appear as papules/pustules on the skin with a dimple in the middle of the lesion. The lesions are typically similar in size and at the same stage (usually all scab at the same time). However, it appears that some of the current cases have had atypical features. The rash is still characteristic, but often starts in the genital and perianal areas. The rash sometimes does not spread to other areas of the body. It is being recognized at outpatient clinics, but being easily confused with sexually transmitted infections because of the location of the rash in the genital and perianal areas. The prodromal symptoms have been mild or not present in the most recent cases. Currently, there have been no reported deaths with infections outside the endemic areas.

The monkeypox virus is spread by direct or indirect contact with body fluids or lesion materials, contact with non-living objects that have viral particles on them, and exposure to respiratory secretions (either on objects or aerosolized). A patient is infectious once symptoms begin and is infectious until lesions scab and the scabs fall off. It is not easily transmitted as viruses such as SARS-CoV-2.

Finally, while the virus is not expected to reach pandemic proportions, the spread is being followed very closely by public health agencies. There are treatments and vaccines available for high risk situations. But, because of its confusion with other rashes (especially sexually transmitted infections that present with genital or perianal rashes), monkeypox can easily be mistaken as some other infection, initially, and can be incorrectly managed. One must have a high index of suspicion for monkeypox. But, if there is any concern or question about monkeypox, reaching out to the CDC or one’s local health department to help guide in diagnosis or treatment is prudent.

Click the link for an infographic that summarizes the basic monkeypox information nicely.