monkeypox (mpox)

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Introduction

  • U.S, Health and Human Services Secretary Xavier Becerra declared monkeypox a public health emergency on August 4, 2022.[14]

Etiology

* electron microscopic image of monkeypox virions, obtained from a skin specimen associated with the 2003 prairie dog outbreak is shown[7]

  • a high-resolution (5.2 MB) is also available on the page

Epidemiology

  • first isolated in 1958 from monkeys at the Statens Serum Institut in Copenhagen, Denmark (thus the name monkeypox)[6]
  • zoonotic infection with most cases from consumption or contact with small mammals, particularly rodents (rope squirrels, tree squirrels, Gambian pouched rats, & dormice)[4][6]
  • associated with exposure to small forest animals (blood contact, bite)
  • first known human case of monkeypox in 1970 in the Democratic Republic of the Congo[6]
  • 59 cases reported between 1970 and 1980 in rain forests of western & central Africa
  • 404 cases between 1981 and 1986 (WHO sponsered active surveillance program)
  • ~800 cases Africa 1996-1998
  • 53 cases (as of 6/03/22) in United States associated with prairie dogs acquired as pets, which were presumed to have acquired the virus from Gambian giant rats housed with them
  • cases reported in Europe & Canada 2022[1]
  • Spain, Brazil, & India reported the first monkeypox-related deaths outside of Africa since the start of the 2022 international outbreak[12]
  • 6 people who have tested positive for monkeypox in th U.S. have died as of October 23, 2022[24]
  • > 80% of hospitalized patients with monkeypox have HIV1 co-infection[25]
  • deadly type of MPOX spreading in the Democratic Republic of the Congo in Fall of 2023

transmission

  • low person to person transmission
  • monkeypox is not spread by casual contact[16]
  • average incubation period for symptom onset is 5-13 days
  • considerable pre-symptomatic transmission[26]
  • transmitted through contact with bodily fluids & sores, or via large respiratory droplets with prolonged face-to-face contact
  • unknown if monkeypox can be transmitted by persons without skin lesions
  • transmission through fomites (bedding or clothes contaminated with material from monkeypox lesions) & from animals to humans have been reported[3]
  • transmission may occur across the placenta to the fetus[16]
  • patient is no longer contagious when lesions crust over to scabs
    • crusts have separated & fresh skin forms underneath[2]
  • household surfaces of symptomatic patients may be contaminated with PCR-detected virus, but no samples have been culturable implying lack of risk for transmission (single home tested)[17]
  • second home tested found viable virus cultured from 60% of porous surfaces (bedding, clothing) after 15 days at low titers indicative of limited potential for indirect transmission[17]
  • potential risk of transmission of monkeypox virus through fecal microbiota for transplantation[18]
  • a Florida nurse developed monkeypox infection after an accidental needlestick[23]

Pathology

Genetics

  • dsDNA virus[8]
  • monkeypox of 2022 outbreak belongs to clade 3, most likely of a single origin.
  • 2022 outbreak lineage B.1 clusters with 2018-2019 cases linked to an endemic country, but segregates in a divergent phylogenetic branch, a result of continuous accelerated evolution[8]

Clinical manifestations

* images[4][19]

Laboratory

  • samples for diagnosis of monkeypox should be collected using a nylon, polyester, or Dacron swab preferably from an open skin lesion place swabbed specimen in a dry, sterile container & keep refrigerated or frozen until testing[6]
    • no date to support use of other sample types (blood, saliva ...)[16]
  • CDC's nonvariola orthopoxvirus polymerase chain reactio n test (FDA-approved)
    • testing has expanded to 5 commercial laboratories[16]
    • details can be obtained from the CDC
  • HIV1 serology if HIV1 status unknown

Complications

Differential diagnosis

Management

* both monkeypox & smallpox are orthopoxviruses

More general terms

References

  1. 1.0 1.1 AMA Morning Report. May 20, 2022 American Medical Association
  2. 2.0 2.1 2.2 2.3 Walker M CDC: Monkeypox May Present With Genital Sores, No Prior Fever. Travel history, close contact, and intimate casual encounters between men all risk factors. MedPage Today May 20, 2022 https://www.medpagetoday.com/infectiousdisease/publichealth/98856
  3. 3.0 3.1 Harris E What to Know About Monkeypox. JAMA. Published online May 27, 2022. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35622356 https://jamanetwork.com/journals/jama/fullarticle/2793012
  4. 4.0 4.1 4.2 4.3 Graham MB, Fairley J, Gunkel JL Monkeypox 2022: A Spreading Threat. Medscape. May 31, 2022 https://reference.medscape.com/slideshow/monkeypox-6015388
  5. Cohen J Concern grows that human monkeypox outbreak will establish virus in animals outside Africa. New "reservoirs" could make outbreaks common and spawn new variants. ScienceInsider. Health. June 8, 2022 https://www.science.org/content/article/concern-grows-human-monkeypox-outbreak-will-establish-virus-animals-outside-africa
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Guarner J, del Rio C, Malani PN Monkeypox in 2022 - What Clinicians Need to Know JAMA. Published online June 13, 2022 https://jamanetwork.com/journals/jama/fullarticle/2793516
  7. 7.0 7.1 7.2 Goldsmith CS Centers for Disease Control & Prevention (CDC) Public Health Image Library. Created 2003 https://phil.cdc.gov/Details.aspx?pid=22664
  8. 8.0 8.1 8.2 Fiore K Monkeypox Outbreak Strain Has Far More Mutations Than Expected
    Evidence of continued adaptation may account for suspected increase in transmissibility. MedPage Today June 24, 2022 https://www.medpagetoday.com/infectiousdisease/generalinfectiousdisease/99408
    Isidro J, et al Phylogenomic characterization and signs of microevolution in the 2022 multi-country outbreak of monkeypox virus. Nature Med 2022; June 24 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35750157 https://www.nature.com/articles/s41591-022-01907-y
  9. California Department of Public Health Healthcare Provider Health Advisory: Managing Monkeypox Virus Infection in California, Updated June 23, 2022. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Health-Advisory-Monkeypox-Virus-6-23-22.aspx
  10. Fiore K U.S. Expands Monkeypox Vaccination Strategy
    Those with presumed exposure now eligible; Jynneos is preferred vaccine. MedPage Today June 29, 2022 https://www.medpagetoday.com/washington-watch/washington-watch/99497
  11. Girometti N et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: An observational analysis. Lancet Infect Dis 2022 Jul 1; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/35785793 https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00411-X/fulltext
  12. 12.0 12.1 Ingram I Monkeypox Deaths Spread; Physician Suicide Rocks a Nation; Popular Sunscreen Recall. Health news and commentary from around the Web gathered by MedPage Today staff. MedPage Today August 1, 2022 https://www.medpagetoday.com/infectiousdisease/covid19/99996
    Scherer L Monkeypox Fatalities Reported as Cases Escalate. Medscape. August 2, 2022 https://www.medscape.com/viewarticle/978431
  13. Dotinga R How Well Does the Monkeypox Vax Work? No One Knows for Sure. Health officials hang hopes on Jynneos, but vaccine not yet proven to protect against infection. MedPage Today August 1, 2022 https://www.medpagetoday.com/special-reports/exclusives/100010
  14. 14.0 14.1 Diamond D Monkeypox is 'a public health emergency,' U.S. health secretary declares. Washington Post. August 4, 2022 https://www.washingtonpost.com/health/2022/08/04/monkeypox-public-health-emergency-united-states-becerra/
  15. 15.0 15.1 AMA Morning Report. August 10, 2022 American Medical Association (AMA)
    Frieden J Biden Administration Authorizes Intradermal Use of Monkeypox Vaccine. Move is expected to increase available doses by five-fold. MedPage Today August 10, 2022 https://www.medpagetoday.com/publichealthpolicy/publichealth/100148
  16. 16.0 16.1 16.2 16.3 16.4 16.5 16.6 16.7 16.8 del Rio C, Malani PN Update on the Monkeypox Outbreak. JAMA. Published online August 11, 2022. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35951336 https://jamanetwork.com/journals/jama/fullarticle/2795359
  17. 17.0 17.1 17.2 Hein I CDC Examines Monkeypox's Ability to Linger on Home Surfaces. Investigators find no viable virus on high-contact areas, but study has caveats. MedPage Today August 19, 2022 https://www.medpagetoday.com/infectiousdisease/generalinfectiousdisease/100325
    Pfeiffer JA, Collingwood A, Rider LE et al. High-Contact Object and Surface Contamination in a Household of Persons with Monkeypox Virus Infection - Utah, June 2022. MMWR Morb Mortal Wkly Rep. ePub: 19 August 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36006842 Free article https://www.cdc.gov/mmwr/volumes/71/wr/mm7134e1.htm
    Morgan CN, Whitehill F, Doty FB et al. Environmental persistence of monkeypox virus on surfaces in household of person with travel-associated infection, Dallas, Texas, USA, 2021. Emerg Infect Dis 2022 Aug 11; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/35951009 Free article https://wwwnc.cdc.gov/eid/article/28/10/22-1047_article
  18. 18.0 18.1 FDA Safety Alert. August 22, 2022 Safety Alert Regarding Use of Fecal Microbiota for Transplantation and Additional Safety Protections Pertaining to Monkeypox Virus. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/safety-alert-regarding-use-fecal-microbiota-transplantation-and-additional-safety-protections-0
  19. 19.0 19.1 Escudero-Tornero R, Sobral-Costas TG, Servera-Negre G Images in Dermatology. Monkeypox Infection. JAMA Dermatol. Published online August 25, 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36006652 https://jamanetwork.com/journals/jamadermatology/fullarticle/2795693
  20. 20.0 20.1 Pastula DM et al. Two cases of monkeypox-associated encephalomyelitis - Colorado and the District of Columbia, July-August 2022. MMWR Morb Mortal Wkly Rep 2022 Sep 23; 71:1212 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36136957 Free article https://www.cdc.gov/mmwr/volumes/71/wr/mm7138e1.htm
  21. 21.0 21.1 Spicknall IH, Pollock ED, Clay PA, et al. Modeling the Impact of Sexual Networks in the Transmission of Monkeypox virus Among Gay, Bisexual, and Other Men Who Have Sex With Men - United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1131-1135 https://www.cdc.gov/mmwr/volumes/71/wr/mm7135e2.htm
  22. 22.0 22.1 Thornhill JP, Barkati S, Walmsley S et al Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. 2022 Aug 25;387(8):679-691 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35866746 https://www.nejm.org/doi/10.1056/NEJMoa2207323
  23. 23.0 23.1 Bascom E Accidental needlestick makes Florida nurse first case of occupationally acquired monkeypox. Helio. Oct 17, 2022 https://www.healio.com/news/primary-care/20221017/accidental-needlestick-makes-florida-nurse-first-case-of-occupationally-acquired-monkeypox
  24. 24.0 24.1 Frehse R, Dillinger K, Elassar A Six people who tested positive for monkeypox have died, health departments confirm. CNN Health. October 23, 2022 https://www.cnn.com/2022/10/23/health/monkeypox-dead-outbreak-us/index.html
  25. 25.0 25.1 Firth S CDC: HIV Coinfection in Over 80% of Hospitalized Monkeypox Cases. Researchers advised testing all sexually active patients with suspected monkeypox for HIV. MedPage Today October 27, 2022 https://www.medpagetoday.com/hivaids/hivaids/101454
  26. 26.0 26.1 26.2 26.3 Ward T, Christie R, Paton RS et al Transmission dynamics of monkeypox in the United Kingdom: contact tracing study. BMJ 2022;379:e073153. Nov 2 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36323407 https://www.bmj.com/content/379/bmj-2022-073153
  27. 27.0 27.1 27.2 27.3 Feller S WHO renames monkeypox to avoid racist, stigmatizing connotations. Healio. Infectious Disease News. Nov 28, 2022 https://www.healio.com/news/infectious-disease/20221128/who-renames-monkeypox-to-avoid-racist-stigmatizing-connotations
  28. 28.0 28.1 Cowen EW, Tkaczyk ER, MD, Norton SA et al Mpox - A Rapidly Evolving Disease JAMA Dermatol. Published online February 9, 2023. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36757705 https://jamanetwork.com/journals/jamadermatology/fullarticle/2801480
  29. 29.0 29.1 29.2 Finamor LPS, de Freitas D, Andrade G et al Tecovirimat Treatment for Monkeypox Virus Keratouveitis. JAMA Ophthalmol. 2023;141(2):210-212. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36547989 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2799981
  30. AMA Morning Rounds. Dec 8, 2023 American Medical Association
  31. http://www.cdc.gov/ncidod/monkeypox
    https://www.cdc.gov/poxvirus/monkeypox/clinicians/case-definition.html

Patient information

monkeypox (Mpox) patient information