What is the treatment for Mpox (monkeypox)?

Treatment for Mpox (Monkeypox)

The primary treatment for mpox includes supportive care, with tecovirimat (TPOXX) as the antiviral of choice for severe cases or immunocompromised patients, while vaccination can be used for post-exposure prophylaxis within 4 days of exposure. 1, 2

Clinical Presentation and Diagnosis

Mpox presents with:

• Initial prodromal symptoms: fever (62-72%), lymphadenopathy (56-86%), myalgia (31-55%), malaise (23-57%), and headache (25-55%) 3
• Characteristic rash that progresses through 4 stages over 2-4 weeks:
  • Macules → papules → vesicles → pustules
• Recent outbreaks have shown a shift toward predominant anogenital lesions 1
• Incubation period: median 7-10 days 3

Diagnosis is confirmed through polymerase chain reaction (PCR) testing of lesion material.

Treatment Algorithm

1. Supportive Care (First-Line)

• Pain management with appropriate analgesics
• Maintain hydration and nutrition
• Prevent secondary bacterial infections
• Keep lesions clean and dry 4

2. Antiviral Therapy

Indications for antiviral treatment:

• Severe disease (extensive rash >100 lesions, high fever, significant constitutional symptoms)
• Immunocompromised patients, especially those with CD4 count <200 cells/μL
• Complications present (e.g., pneumonitis, encephalitis)
• Anatomically concerning areas (face, genitals, perianal region)

Antiviral options:

• Tecovirimat (TPOXX): First-line antiviral
  • Dosing: Based on weight, administered orally for 14 days
  • Effectiveness established in animal studies with non-variola orthopoxviruses 2
  • Available through expanded access programs or clinical trials 3
• Brincidofovir: Alternative antiviral option
• Cidofovir: Alternative for severe cases

3. Special Populations

Immunocompromised patients:

• Higher risk for severe disease and complications
• Lower threshold for initiating antiviral therapy
• May require longer treatment duration
• Close monitoring for disease progression

Pregnant women:

• Individualized risk assessment
• Consultation with specialists in infectious diseases and maternal-fetal medicine
• Tecovirimat preferred if treatment indicated

Prevention

Vaccination

Two vaccines are available:

• JYNNEOS™ (Modified Vaccinia Ankara-Bavarian Nordic):

  • Preferred vaccine with 66-86% efficacy
  • Two-dose regimen
  • Can be used for pre-exposure and post-exposure prophylaxis
  • Safer option for immunocompromised individuals 1, 3

• ACAM2000®:

  • Live vaccinia virus vaccine
  • Not recommended for immunocompromised individuals, pregnant women, or those with certain health conditions 5

Post-exposure prophylaxis:

• Ideally administered within 4 days of exposure
• May reduce severity of disease if given up to 14 days after exposure 1

Infection Control Measures

• Isolation until all lesions have crusted over and fallen off
• Avoid close contact, especially skin-to-skin contact
• Cover lesions with clothing or bandages
• Practice good hand hygiene
• Avoid sharing personal items

Common Pitfalls to Avoid

1. Delayed treatment initiation in high-risk individuals
2. Misdiagnosis due to atypical presentation (especially in recent outbreaks with predominant anogenital lesions)
3. Inadequate infection control leading to secondary transmission
4. Overlooking immunocompromised status of patients, particularly those with HIV
5. Applying topical treatments to lesions, which may increase risk of bacterial superinfection 6

Monitoring and Follow-up

• Regular assessment of lesion progression
• Monitor for secondary bacterial infections
• Follow-up until complete resolution of all lesions
• Contact tracing to prevent further transmission

While mpox is typically self-limiting in immunocompetent individuals with a mortality rate <0.2% in the US, early recognition and appropriate management are crucial to prevent complications and limit spread.