What is the management and treatment of monkeypox?

Management and Treatment of Monkeypox

Monkeypox treatment primarily consists of supportive care, but for severe cases or immunocompromised patients, tecovirimat is the recommended first-line antiviral therapy. 1

Clinical Presentation

Monkeypox presents with the following characteristics:

• Initial symptoms include fever, severe headache, lymphadenopathy, myalgia, and fatigue 2
• Skin lesions typically erupt within 1-3 days after fever onset
• Rash tends to be more concentrated on the face and extremities rather than the trunk 2
• The disease is usually self-limiting, with symptoms lasting 2-4 weeks 3

Treatment Algorithm

1. Supportive Care (First-line for most patients)

• Pain management with appropriate analgesics
• Adequate hydration
• Wound care for lesions
• Isolation until all lesions have crusted over 1

2. Antiviral Therapy Indications

Antivirals should be considered for:

• Immunocompromised patients
• Severe disease (>100 lesions, high fever, significant constitutional symptoms)
• Complications (encephalitis, pneumonia, retropharyngeal abscess)
• Lesions near critical areas (eyes, mouth, genitals) 1

3. Antiviral Options

• First-line: Tecovirimat 600 mg twice daily orally for 14 days 1
  • Demonstrated significant improvement in survival in animal studies with monkeypox 4
  • Most effective when initiated within 4-5 days of symptom onset 4
• Second-line: Cidofovir (when tecovirimat is ineffective)
  • Limited by nephrotoxicity and IV-only administration 1

Infection Control Measures

• Isolate patient until all lesions have crusted over and scabs have fallen off 1
• Frequent handwashing with soap and water or disinfectants containing >60% alcohol 5
• Avoid direct contact with lesions 5
• Place used bandages in sealed plastic bags for disposal 5
• Healthcare workers should use appropriate personal protective equipment

Prevention

Vaccination

Two vaccines are available:

• JYNNEOS™ (preferred): Live non-replicating vaccinia virus vaccine 6
• ACAM2000®: Live replicating vaccinia virus vaccine (more side effects) 6

Vaccination is recommended for:

• Pre-exposure prophylaxis for high-risk individuals
• Post-exposure prophylaxis (ideally within 4 days of exposure) 1

Special Populations

Immunocompromised Patients

• Higher risk of severe disease
• Should receive antiviral treatment early
• May require longer duration of therapy 1

Pregnant Women

• Consider antivirals due to potential risk of severe disease and fetal complications 6
• Benefit-risk assessment should be performed before initiating treatment

Complications to Monitor

• Secondary bacterial infections of skin lesions
• Pneumonia
• Encephalitis
• Kidney injury
• Myocarditis (particularly in children and immunocompromised individuals) 7

Prognosis

• Case fatality rate is typically low (<0.1% in non-endemic countries) 3
• Most patients have self-limited illness
• Hospital admission rates range from 1% to 13% (for treatment or isolation) 3

The management of monkeypox requires a systematic approach focusing on supportive care for most patients, with targeted antiviral therapy for those at risk of severe disease. Proper infection control measures are essential to prevent transmission to healthcare workers and close contacts.