UMEM Educational Pearls

Background:

• Monkeypox virus (MPXV) has two distinct genetic clades (subtypes of MPXV), I and II, which are endemic to central and west Africa, respectively. 
• The global mpox outbreak that began in 2022 is caused by MPXV II
• The recent outbreak in Democratic Republic of Congo (DRC) is caused by MPXV I

What’s new?

• Democratic Republic of Congo (DRC) has reported more than 22,000 suspect cases of MPXV I since January 1, 2023 (annual median of 3,767 suspect MPXV I cases in prior 6 years)
• Largest number of yearly suspected MPXV I cases ever recorded 
• More widespread than any previous outbreak, resulting in transmission to neighboring countries [Republic of the Congo (ROC), the Central African Republic (CAR), Burundi, Rwanda, and Uganda].

Who is at risk?

Patients with epidemiologic characteristics and lesions or other signs and symptoms consistent with mpox. This includes anyone with travel to DRC or any of its neighboring countries (ROC, CAR, Rwanda, Burundi, Uganda, Zambia, Angola, Tanzania, and South Sudan) in the previous 21 days.

What to look for? 

• Rash that may be located on the hands, feet, chest, face, mouth, anus or near the genitals
• Lesions are firm or rubbery, well-circumscribed, deep-seated, and often develop umbilication (see below).

(Above photos from https://www.cdc.gov/poxvirus/mpox/clinicians/clinical-recognition.html)

• Lesions progress through four stages—macular, papular, vesicular, to pustular—before scabbing over and desquamation. They are often described as painful until the healing phase when they become itchy (crusts).
• Fever, chills, swollen lymph nodes 
• Fatigue, myalgia (muscle aches and backache), headache
• Respiratory symptoms like sore throat, nasal congestion, and cough
• Illness lasts 2-4 weeks
• Once all scabs have fallen off and a fresh layer of skin has formed, a person is no longer contagious.

What to do?

If mpox is suspected in a patient:

• Isolate the patient in a single patient room (no special air filtration is required).
• Use PPE (Gown, gloves, eye protection, and NIOSH-approved particulate respirator equipped with N95 filters or higher).
• Intubation and any procedures likely to spread oral secretions should be performed in an airborne infection isolation room.
• Notify your local health department immediately.
• Evaluate all suspected cases related to DRC or its neighboring countries with laboratory testing (rather than clinical diagnosis alone). 
• Counsel patients about staying away from other people and not sharing things they have touched with others; and cleaning and disinfecting the spaces they occupy regularly to limit household contamination.
• Recommend mpox vaccine to asymptomatic close contacts of cases of MPXV.
• Offer treatment with oral tecovirimat (TPOXX), available through the STOMP Trial. To enroll in STOMP, in the US call 1-855-876-9997.

References