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Adapted image from the Centers for Disease Control and Prevention (CDC). [Public domain.]
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

Monkeypox is the topic of many news reports of late. While monkeypox has been endemic to Central and West Africa since the early 1970s, the disease began a significant spread outside of that area in early May 2022. As of May 26, 2022, over 300 monkeypox cases have been confirmed in 20 non-African nations and 6 US states.[1] The situation continues to evolve rapidly.

Background

Monkeypox is an orthopoxvirus with a clinical presentation like that of smallpox.[2] Although initially identified in monkeys in 1958, the first identified outbreak in humans occurred in the Democratic Republic of Congo (DRC) in the early 1970s.

Shown is a boy with the maculopapular rash characteristic of monkeypox covering most of the cutaneous surface. The photograph is from a 1997 monkeypox outbreak in the DRC.

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Image from the CDC | Cynthia S Goldsmith, Russell Regnery. [Public domain.]
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

The electron microscopy image above shows monkeypox virion isolated from a human skin sample during the 2003 US outbreak. Oval-shaped, mature virus particles are on the left, with immature, spherical particles on the right.

Transmission

Monkeypox is zoonotic, with transmission to humans occurring from contact with or consumption of small mammals, particularly rodents.[3] In 2003, several dozen human cases of monkeypox were identified in the United States and traced to pet prairie dogs and, ultimately, to rats imported from Ghana. Human-to-human transmission has also been reported, with the virus entering the body through broken skin, respiratory droplets, or mucous membrane exposure.[4] Indirect contact with lesion material, such as through contaminated clothing or linens, is also a hypothesized transmission route.

Several of the confirmed cases in the 2022 outbreak are in men who have sex with men, raising the question of the exact human-to-human modes of transmission.[5] Exposure to human body fluids, respiratory droplets, and direct contact with monkeypox sores remain primary concerns for spread.

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Image of lymphadenopathy in a patient with monkeypox courtesy of Medscape.
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

Signs and Symptoms

Early symptoms of monkeypox infection typically include fever and lymphadenopathy, often associated with headache, myalgias, chills, fatigue, and cough. Lymphadenopathy is the most reliable clinical sign that differentiates monkeypox from smallpox and chickenpox, particularly enlarged submental, submandibular, cervical, and inguinal lymph nodes.[6]

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Image of a patient with monkeypox lesions on the torso and right upper extremity from the CDC. [Public domain.]
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

The incubation period for monkeypox is usually 7-14 days but can range from 5 to 21 days. The rash typically develops 1-3 days after the onset of fever, often beginning on the face/mouth and spreading rapidly to the rest of the body, including the palms and soles. The rash appears similar to that of chickenpox. Monkeypox lesions tend to progress through macular, papular, vesicular, and pustular stages before resolution. The illness occurs for 2-4 weeks, with some patients having ulcerative lesions.[7]

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Image of clinicians wearing personal protective equipment (PPE) from Wikimedia Commons | Javed Anees, District Hospital, Tirur. [CC 1.0 Universal (CC0 1.0).]
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

Evaluation

When evaluating a patient with suspected monkeypox, droplet precautions should include PPE, such as an N95 mask, gown, gloves, and eye protection. Conduct a travel and exposure history: When confirmed, maintain a log of all clinical teammates that have had patient exposure. Appropriately disinfect patient room surfaces after the patient departs.

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Image of the face of a recovered patient with resulting pockmarks from the CDC. [Public domain.]
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

Obtain a viral culture from an oropharyngeal or nasopharyngeal swab. A skin biopsy specimen of the vesiculopustular rash or a sample of the roof of an intact vesiculopustule should be analyzed. Monkeypox can be confirmed via polymerase chain reaction (PCR), electron microscopy examination (in the absence of other orthopoxviruses), or immunohistochemical testing.[8]

A Tzanck smear can help differentiate monkeypox from other nonviral disorders in the differential diagnosis. However, a Tzanck smear does not differentiate a monkeypox infection from smallpox or herpetic infections.

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Image courtesy of Medscape.
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

A monkeypox vesiculopustular rash on the dorsum of a patient's hand is shown. Note the central umbilication of some lesions.

Treatment

Treatment for monkeypox infection is largely supportive and symptomatic. It is crucial to isolate patients and take appropriate precautions to prevent spread of the disease. The patient is contagious until all scabs have dried and fallen off. Monkeypox vaccines are available, and vaccination after high-risk exposure has been shown to prevent disease or mitigate severity in some cases.[9]

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Image from the CDC. [Public domain.]
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Monkeypox 2022: A Spreading Threat

Mary Beth Graham, MD, FIDSA, FACP; Janet Fairley, MD, FAAD; Juliet L Gunkel, MD | May 31, 2022 | Contributor Information

The palms of a monkeypox patient with a maculopapular rash are shown. The image is from the DRC monkeypox outbreak in 1997.

Mortality and Complications

No monkeypox-related deaths have ever been recorded in the United States. However, mortality in Africa is between 1.0% and 10.6%, with high-risk individuals (eg, immunocompromised, malnourished) having worse outcomes.[10] Secondary bacterial infections can also occur.

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