The clinical features, diagnostic tools, and management of monkeypox infections, offering crucial insights into how the virus spreads, its impact on high-risk populations, and the effectiveness of current treatments and vaccines.
Study: Mpox Clinical Presentation, Diagnostic Approaches, and Treatment Strategies. Image Credit: karacacennet/Shutterstock.com
A recent review in JAMA discusses monkeypox clinical presentation and management options.
Background
Monkeypox virus (MPXV) is a double-stranded DNA virus classified into two clades: Clade I, which is endemic to Central African nations, and Clade II, which is endemic to Western African countries.
The clade IIb MPXV outbreak expanded swiftly across 118 nations, leading to a population health emergency requiring global concern between July 2022 and May 2023. The outbreak impacted about 99,000 individuals globally, caused over 33,000 illnesses, and resulted in 60 fatalities in the United States.
A recent study in eastern DRC discovered a novel emerging strain known as clade Ib, emphasizing the need for increased surveillance and global vaccination equity to address the ongoing public health issue.
About the review
The present review highlights the clinical features, diagnostic techniques, and treatment protocols for monkeypox infections.
Using the PubMed database, the researchers examined monkeypox records from January 1, 1975, to September 13, 2024, focusing on high-quality randomized clinical trials (RCTs) and longitudinal observation studies.
They also checked government websites for updated instructions. The study used 111 citations, including one RCT, 59 longitudinal studies, 23 reviews, 13 government websites, fundamental science papers, four case reports, and one news release.
Clinical presentation of monkeypox
Humans most commonly contract mpox by direct contact with the monkeypox virus, which can spread through infected lesions, body fluids, bites, scratches, contaminated fomites, and respiratory droplets.
Clade IIb infections are frequent among homosexuals, bisexuals, and males having sex with males. Clade Ia MPXV transmission is driven by zoonotic exposure and household distribution, with a considerable number of infections occurring in children.
MPXV attacks immune cells and nearby lymph nodes. It multiplies quickly, spreading throughout the lymphatic system and circulation, infecting many organs and harming the host. The median incubation time ranges between seven and 10 days.
After the asymptomatic incubation phase, prodromal symptoms such as fever, lymphadenopathy, headaches, myalgias, and malaise appear before or after the rash begins.
Painful skin lesions range from macules and papules to vesicles and pustular lesions. The last stage is crusty and desquamate. These lesions may develop concurrently. Patients with mpox remain infectious until all lesions have re-epithelialized, which can take up to four weeks.
The Mpox rash, which commonly affects the face, torso, and limbs, can result in genital, anogenital, oral, and perioral lesions upon sexual intercourse. Few lesions (median, less than 10) may appear and develop unevenly.
Mpox consequences include proctitis, pharyngitis, urethritis, and ophthalmic illness. It can also induce necrotizing skin lesions with bacterial superinfection, pneumonia, and encephalitis, particularly among immunocompromised individuals.
Monkeypox diagnosis and treatment
Clinicians should suspect Mpox among individuals with skin lesions and potential MPXV exposure. Polymerase chain reactions (PCR) confirm Mpox.
Differential diagnoses include secondary syphilis, herpes simplex virus, impetigo, and cellulitis. Secondary syphilis lesions are painless. Herpes simplex, impetigo, and cellulitis present with painful pustular or vesicular lesions similar to monkeypox.
First-line treatment for mpox is supportive care with pain control using analgesics and wound care. Supportive care for skin and genital lesions includes lidocaine gel and non-steroidal anti-inflammatory medicines. The lesions must be clean and dry. If infected, the lesions need debridement with wet-to-dry dressings, and antibiotics are required.
The United States Food and Drug Administration (FDA) has not approved antiviral treatments for Mpox patients. However, several therapeutics, such as vaccinia immune globulin intravenous (VIGIV), brincidofovir, and tecovirimat, are available via clinical trials and expanded accessibility programs. VIGIV administration involves a single dose of 6,000 to 9,000 units/kg.
Brincidofovir is administered orally in a 200 mg dosage weekly over two weeks but can elevate liver enzymes. Tecovirimat is administered orally (600 mg) and intravenously (200 mg) but is contraindicated for patients with creatinine clearance below 30 mL per minute.
The Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine is 66%-86% effective among high-incidence adults. The Advisory Committee on Immunization Practices (AICP) recommends the MVA-BN vaccine as preexposure prophylaxis for nonoccupational-risk adults, including gay, bisexual, transgender, nonbinary, newly diagnosed, multiple-sex partners, or individuals engaging in sex at commercial venues or public events in regions of high MPXV transmission.
The Centers for Disease Control and Prevention (CDC) recommends MVA-BN vaccination for post-exposure prophylactic care for those with known or presumed exposure. It is ideally administered within four days of MPXV exposure but can be given up to 14 days after exposure.
Conclusion
Based on the findings, monkeypox refers to a viral disease transmitted through direct skin contact. It causes self-resolving disease but potentially severe morbidity and mortality among immunocompromised individuals.
Supportive care is the first-line treatment, but healthcare professionals may consider advanced therapeutics for severe cases.
Monkeypox vaccinations are effective, and high-risk individuals must receive them. Clinicians must recognize monkeypox's characteristic signs and symptoms for timely diagnosis and appropriate management.
African production of mpox vaccines could secure the continent’s health