Monkeypox has arrived. Is the panic justified? St Emlyn’s

This blog provides a rapid update on the diagnosis and management of the emerging infection ‘MonkeyPox’. If you want the short answer to the question then it’s no. Don’t panic, but do read on to find out more.

I have to confess that I had not heard of monkeypox until recently when the news of two imported cases1 hit the UK news and our Public Health services started sending official warnings to our EDs last week.

As usual, I jumped on the occasion and looked into this mysterious and strange re- emerging disease. Here is short StEmlyns update for you all to peruse. As always hot off the press…

What is monkeypox?

The disease is caused by the monkeypox virus (genus orthopox). The virus is related to, but distinct from, the viruses that cause smallpox (variola virus) and cowpox. You can however expect similar clinical features to chickenpox (which you will all be familiar with as EPs) but I will expand on this a bit further down. For the moment, keep the picture of a patient with chickenpox in your head…

Monkeypox was first discovered in 19582 when a pox-like illness broke out in primates kept and used for research (Ed – this could be a great Hollywood film story and follow the Planet of the Apes franchise). The first human case was described later in 1970 in the Democratic Republic of Congo (that is the ex-Zaire: you need to know your geography if you want to be a good infectious disease expert!), which seems to be a hot bed for some other nasty infectious diseases like Ebola and other viral haemorrhagic fevers.

Worthwhile mentioning that an outbreak occurred in the USA in 2003 with imported rodents thought to be the source of the infected. I blame globalisation and the spread of cheap flights.

In 2008, an outbreak was reported in Cameroon (it is where I grew up and spent my childhood 😮, the Central African Republic, Liberia, Nigeria and the Democratic Republic of Congo and then like with every outbreak, all went quiet for a while.

Finally, earlier this month two imported cases were reported in the UK. One in the seaside resort of Blackpool in the North of England and the other on a naval base in Cornwall down south. There is not thought to be any UK epidemiological link between the two cases but worth noting that both cases had recently returned from Nigeria so it is fair to assume that it was where the infections were acquired.

How is it transmitted?

Despite both recent cases being diagnosed in UK seaside towns, the British sea water can only be blamed for its temperature this time of the year.

The primary vector for the disease are infected rodents. Humans get infected when they come into close contact with an animal or contaminated materials (like towels or bedsheets). Direct transmission is also possible when infection occurs via infected wounds/scabs.

The virus enters the body through broken skin (even if breaks are not visible), the respiratory tract, or the mucous membranes (eyes, nose, or mouth).

Despite the recent public health alerts and media attention, monkeypox does not spread easily and remains a rare disease in temperate climates.

What does the patient look like?

The incubation period is approximately 14 days (5 to 21 days). Monkeypox is usually a self-limiting disease but the immuno-compromised, the multi-morbid, the elderly and paediatric patients are at risk of potential complications.

Presenting symptoms include: fever, exhaustion, myalgias, lymphadenopathy and…a rash.

Monkey Pox rash from wikipedia

The rash may be maculo-papular initially, typically starting on the face before spreading peripherally, particularly to the palms of the hands and the soles of the feet.

The initial rash classically evolves into vesicles and then pustules, often with umbilication, which eventually crust and then desquamate during the next two to three weeks. These characteristic pox lesions are typically 0.5 to 1cm diameter and may number from a few to several thousand. (Ed – did I mention earlier “like chickenpox”?)

Involvement of the oral mucous membranes occurs in many cases.

Diagnosis can be difficult as it gets often confused with chickenpox and you need to link clinical picture with travel history/exposure. Specialist assessment and laboratory investigation are essential. In the UK, you will be contacting your local virology services and/or the Imported Fever Services3 for help which provides access to expert clinical and microbiological advice 24/7.

Is there a treatment at all?

The illness being self-limiting and often mild, the treatment is mostly supportive. Recovery takes a few weeks. (Ed – yes, like chickenpox)

What should I do in my ED?

Two imported cases so far hardly mandates a full scale Ed preparedness plan but it is best to consider the below:

  • Make sure you follow your local public health alerts (and read our blogs!).
  • Take a thorough travel history4 in any patients presenting with a fever or a history of fever. You should be doing this routinely anyway…
  • Isolate suspected and confirmed cases
  • Use routine barrier protection in all patients’ contact and appropriate personal protection equipment (PPE) if any suspicion of monkeypox
  • Seek specialist help from your local virology and/or public health services in suspected cases as this is highly hazardous pathogen with potentially a tricky diagnosis

Play safe folks!

Janos

@baombejp on Twitter

 

References:
1.
Monkeypox case in England. GOV.UK. https://www.gov.uk/government/news/monkeypox-case-in-england. Published 2018. Accessed September 21, 2018.
2.
Parker S, Buller R. A review of experimental and natural infections of animals with monkeypox virus between 1958 and 2012. Future Virol. 2013;8(2):129-157. [PMC]
3.
Imported fever service (IFS). GOV.UK. https://www.gov.uk/guidance/imported-fever-service-ifs. Published 2018. Accessed September 21, 2018.
4.
Baombe J. Taking a travel history in the ED by StEmlyns – St.Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/taking-travel-history-ed-stemlyns/. Published September 22, 2017. Accessed September 21, 2018.

Posted by Janos Baombe

Dr Janos Baombe MD, FRCEM, FEEBEM, PgCert, MSc is section editor and editorial board member on the St Emlyn's blog and podcast. He is a consultant in emergency medicine in Manchester and visiting senior lecturer at Manchester Metropolitan University. His research interests include infectious disease, European emergency medicine networks, ultrasonogaphy, toxicology, HIV/AIDS, EBM. You can find him on twitter as @baombejp

  1. […] Monkey Pox has re-emerged… but is it important? Janos Baombe from St Emlyn’s takes us through its features. [SO] […]

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