So this is our second infectious disease outbreak, monkeypox.
I might add, parenthetically so to speak, that the Centers for Disease Control and Prevention has just released a case report on the first case in 10 years of paralytic poliovirus in the United States as I write this.
I should add, also in parentheses, that last week the World Health Organization asked for help in renaming monkeypox, and the favorites I’ve heard are OPOXID-22 (orthopoxvirus disease 2022) and MPXV (monkeypox virus).
I practice in San Francisco, and we’ve been relatively spared in terms of COVID cases and deaths, but we’ve been hit hard by monkeypox. We have the highest number of monkeypox cases per capita of any major city. (Los Angeles, for example, has about 150 more patients than San Francisco, but about nine million more people.)
Why you will see Monkeypox
Monkeypox is an orthopox virus that was first identified in 1958 in Copenhagen (which is why I think it should be called DenBrands, But this is another story). It has been identified in some monkeys in a lab there, but monkeys are probably not the reservoir host for this virus. These are probably adorable African squirrels. (Image search “sun squirrel” or “rope squirrel”, and deny the cuteness, I dare you). So it’s probably more realistic squirrel pox. In any event.
Monkeypox is endemic in parts of Africa, but Nigerian doctors and the Nigerian Center for Disease Control tried to warn us in 2017 of human-to-human transmission, with particular concern for sexual transmission. First: we have received many warnings. Second: The United States threw away 20 million doses of the currently in-demand JYNNEOS vaccine, which presumably could have been donated or sold to Nigeria to, you know, help with their local monkeypox outbreaks.
Fast forward to last May when we started to see many new cases of monkeypox, especially among men who have sex with men, especially among those with multiple and new sex partners. Add numerous errors at the federal level with several US three-letter agencies, and we have seen cases doubling every 10 to 12 days since the beginning of July.
Almost all cases currently are seen in men who have sex with men (more than 90-95%). We think the greatest way of transmission is skin-to-skin contact, like, say, people having sex (lots of skin, not a lot of clothes).
The lesions we see now (did you know the United States had an outbreak of monkeypox in 2003 in the Midwest?) tender be in areas of the body that are often involved in sexual activity: the genitals, the anus and rectum, and the mouth, but the lesions can honestly be anywhere.
And with cases doubling every two weeks, you’re bound to see at least one case of monkeypox, especially if you live near an urban center (where there are more gay men too).
It might not present itself in a classic way
Let’s talk a little more about these lesions. Even with a “classic” appearance, they can present themselves in many different ways depending on the course of the disease and the person.
- They may start with a tiny macular redness.
- They may then be maculopapular.
- Most turn at some point into the classic “chickenpox” that you might associate with something like chickenpox or smallpox.
- They may also develop an umbilication (a point at the top of the lesion).
- Many later ulcerate and bare their roof.
- Eventually (we’re talking one to three weeks later) they should mange on.
- And then the scabs fall off.
- The patient is then considered cured/cured/no longer contagious.
You will notice that I have used “may” and “should” a lot in this list. It’s because this disease doesn’t necessarily show up the way it…should. You’re going to see a quite different description of monkeypox in a textbook in a few different ways:
- Location: Previous monkeypox infections tended to involve the face and rarely the genitals; we see a large proportion on the genitals this time.
- Quantity: About 10% of patients may have only one solitary lesion; most have between 2 and 10, and a few can have more than 50.
- Mucous membranes: more patients have lesions of the mucous membranes of the mouth or rectum compared to previous outbreaks. About five percent of patients in a series of cases had only mucosal lesions and none on the skin.
- Timing: Previous monkeypox infections tended to have all lesions appear at the same time and all were the same age. This time we see lesions of different ages and stages.
- Prodrome: Classically, patients were all supposed have a uniform prodrome of fevers, headaches, fatigue, and lymphadenopathy before skin lesions form. Rather, we find that about 60% of patients will have a fever, but the lesions may start before the fever or may still behave like a classic “prodrome.”
And (yes, there’s more) we see several other presentations that don’t show up the way you might think monkeypox is “meant” to show up, described in several case series as:
- Peritonsillar abscess, tonsillitis, and tonsillar exudates, possibly with tonsillar fullness or asymmetry.
- Skin Abscess: This looks like a regular old subcutaneous skin abscess that you would gladly cut out, drain, and send home.
- Severe rectal pain: these patients present with isolated rectal pain and symptoms of proctitis; anoscopy reveals multiple lesions which are monkeypox.
- Maculopapular rash: This looks like a nonspecific rash or viral exanthema; turns out it’s monkeypox.
I will say that all the patients I’ve seen have had very classic looking lesions, but an ER doctor friend told me he had a patient he thought had tonsillitis but whose primary care physician later said it was monkeypox.
I think we need to test more of these lesions. Obviously you have to take classic lesions to confirm the diagnosis, but I think the test is really even more important in cases that seem atypical, that maybe don’t have risk or exposure factors, or that you think “It’s possible monkeypox” or “I wonder if it could be monkeypox?” (As I said, all the cases I saw were “It’s definitely monkey pox.”)
Why you don’t want to miss it
This is a perfectly reasonable concern for an emergency physician, especially because our main goal is not to miss life-threatening diagnoses. You’re probably not that upset if you don’t diagnose sarcoidosis yourself, but you’re probably a little disappointed if a patient with shortness of breath rebounds, is admitted for hypoxia and ends up with a diagnosis of sarcoidosis, doesn’t is this not ?
None of us want to be wrong or miss something or bounce back or give bad advice. None of us like to miss a break. Of course, there’s probably not much harm to the patient if you call them back within 24 hours: they get a splint, set up with follow-up, etc. He’ll probably be fine, even if he walked on his broken back. ankle for a day. Same thing with monkeypox: it’s sub-optimal for several reasons:
- A patient can bounce back with pain control issues, sending the diagnosis back to your colleague and potentially exposing other members of your team and community if you fail to make the correct diagnosis.
And these lesions can be extremely painful. I offer several different analgesic modalities: opioids, acetaminophen, NSAIDs, topical lidocaine, gabapentin, and even mesalamine suppositories for patients with severe rectal pain and injury.
- These patients will absolutely isolate themselves and do not want to transmit this disease to anyone else. You probably won’t have same-day PCR to tell them in the ER if it’s monkeypox, but you can at least voice your professional concern by saying you’re pretty sure it’s monkeypox, and I can guarantee you that most patients (especially gay men) are probably in the ER because they’re very suspicious or worried they have monkeypox. But they’re probably not going to take it so seriously if you tell them it looks like strep throat.
- You don’t want to cut a monkeypox lesion and spray monkeypox pus near you or in the air.
- A treatment called Tecovirimat (TPOXX) seems to speed up the healing of lesions (and therefore perhaps also makes patients contagious for a shorter period of time). It’s probably worth putting these patients in touch with your local infectious disease and HIV doctors or county public health team, as they often understand the long and tedious process it takes to get TPOXX from the CDC strategic national stock. (Hopefully it will be more widely available by the time this article goes to print.)
Many of us are working hard to get better access to vaccines, easier access to TPOXX, better and faster testing options, and better education to stop this disease. I hope cases are down, vaccine is plentiful, TPOXX is readily available, and testing is fast as you read this. But one of the reasons I write this is that we need alternatives to mere hopes and prayers.
Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations and risk stratifications, which also has an app (http://apps.mdcalc.com/), and the NST (www.thennt.com), a necessary number tool to deal with to communicate pros and cons. Follow him on Twitter@grahamwalker, and read his past columns onhttp://bit.ly/EMN-Emergentology.