In a recent study published in IDCases, researchers described the case of a male patient with monkeypox.
Monkeypox, a zoonosis, is caused by the monkeypox virus (MPXV) from the Poxviridae family. The vaccinia, variola, and cowpox viruses are from the same family. According to the United States (US) Centers for Disease Control and Prevention (CDC), more than 30,000 monkeypox cases have been identified in the current outbreak from over 80 countries/territories.
Most cases have been detected in Europe, the Americas, Africa, the Western Pacific, and the Eastern Mediterranean. Preliminary reports suggest that most patients are bisexual, gay, and men who have sex with men (MSM). More than 8000 cases of monkeypox have been reported in the US. Developing appropriate strategies to prevent secondary transmission is crucial, yet it is overlooked in the US even as cases soar in numbers.
The study and findings
In the present study, researchers described the case of a 26-year-old patient with monkeypox. The patient was a polygamous, homosexual male with a previous history of syphilis and pre-exposure prophylaxis for human immunodeficiency virus (HIV). The patient visited the emergency room (ER) due to a progressively worsening rash around the mouth and on the tongue, which began five days previous.
The subject reported having unprotected intercourse a day before symptom onset and woke up the next day with lesions on the face, tongue, and around the mouth. Lesions worsened a day later, and the subject experienced a low-grade fever. Upon seeking care, the patient was prescribed nystatin, and Valtrex for suspected infection with herpes simplex virus (HSV).
Symptoms deteriorated despite the ongoing treatment; the number of lesions increased, and the subject had a sore throat, burning sensation in the mouth, swollen tongue, and difficulty swallowing solid food. Physical examination revealed multiple umbilicated pox-like oral and perioral lesions, with oral thrush and palpable lymphadenopathy in the neck.
A cardiac examination revealed tachycardia and regular rhythm. Multiple bilateral enlarged posterior jugular and submandibular lymph nodes were identified in computed tomography of the head/neck with contrast. There was no evidence of swelling of soft tissues in the epiglottis, larynx, or oropharynx. Due to a sepsis alert, the patient was started on antibiotics, including intravenous vancomycin, piperacillin/tazobactam, intravenous dexamethasone with acyclovir, and fluconazole in the ER.
After admission, the infectious diseases and ENT teams were consulted for recommendations. Polymerase chain reaction (PCR) tests were performed to rule out HSV, monkeypox, varicella, and the coronavirus disease 2019 (COVID-19).
All tests were negative except for monkeypox. The fluorescent treponemal antibody absorption (FTA-ABS) test and a follow-up rapid plasma reagin test for syphilis returned positive. Intravenous antiviral and antibiotics were discontinued. The patient was given magic mouth wash, intravenous fluconazole for oral thrush, and intramuscular penicillin.
The patient had no history of recent international travel. Symptoms did not improve much over time, with significant tongue swelling and increased lesions on the third day of hospitalization. The patient was started on tecovirimat (ST-246), and symptoms began improving by the fifth day, with the lesions crusting.
The subject was discharged in a stable condition and instructed to follow up in one week and take ST-246 twice daily for two weeks and fluconazole once daily for five days. The ER and admitting providers evaluated the subject using only surgical masks and gloves, and they remained free from symptoms even after 21 days of exposure to the virus.
Although monkeypox has been endemic in Africa, many countries that have historically not reported monkeypox have been witnessing outbreaks lately. The current outbreak is driven by the West African clade of MPXV, which is less contagious/severe than the Congo Basin clade. The US Food and Drug Administration (FDA) has licensed two smallpox vaccines for monkeypox. The CDC recommends against mass vaccination and suggests limiting it for pre-exposure prophylaxis in high-risk individuals and post-exposure prophylaxis.
Monkeypox treatment is mainly supportive care as most cases are self-limiting and mild. Although no specific drug has been developed, the FDA has approved ST-246 and brincidofovir for pregnant patients, children younger than eight years, and immunocompromised subjects. Overall, MPXV is spreading at an unprecedented rate; thus, it is critical to comprehensively understand the disease epidemiology and improve global cooperation for disease surveillance, better epidemic preparedness, and mitigation of monkeypox.