What are the symptoms, treatment options, and management strategies for monkeypox?

Monkeypox: Clinical Features, Treatment, and Management

Monkeypox is a zoonotic viral infection that presents with characteristic skin lesions and requires supportive care, with antiviral treatment reserved for severe cases. This comprehensive review covers the essential aspects of monkeypox infection management.

Clinical Presentation

Prodromal Phase

• Initial symptoms include fever, severe headache, lymphadenopathy (swollen lymph nodes), myalgia (muscle pain), and fatigue, typically occurring 5-21 days after exposure 1
• The prodromal phase with these non-specific symptoms precedes the development of skin lesions 1

Rash Phase

• Skin lesions typically erupt within 1-3 days after the onset of fever 2
• The rash tends to be more concentrated on the face and extremities rather than the trunk 2
• Lesions progress through distinct stages: macules, papules, vesicles, and pustules 1
• The skin eruptions follow a Jennerian progression (similar to smallpox vaccination sites) 3

Transmission

• Monkeypox can be transmitted through:
  • Close contact with infected humans or animals 2
  • Direct contact with infectious sores, scabs, or body fluids 4
  • Intimate contact during sexual activity 4
  • Respiratory droplets from prolonged face-to-face contact 5
• The 2022 global outbreak was primarily driven by transmission via intimate contact among men who have sex with men (MSM) 1
• Previously, monkeypox was endemic to West and Central Africa, but since 2022, it has been reported in multiple non-endemic countries worldwide 1

Diagnosis

• Diagnosis is primarily made through PCR testing of lesion material 2
• Clinical presentation with characteristic rash and epidemiological factors (such as contact history) guide initial suspicion 2
• Differential diagnosis includes smallpox, chickenpox, herpes infections, and other conditions that cause vesicular or pustular rashes 3

Treatment Options

Supportive Care

• Monkeypox is often self-limiting, with symptoms lasting 2-4 weeks 2
• Supportive care focuses on symptom management and preventing complications 5

Antiviral Medications

• Tecovirimat (TPOXX) is the first-line antiviral treatment for severe monkeypox cases 6
  • FDA-approved for treatment of orthopoxvirus infections, including monkeypox
  • Effectiveness was established through animal studies with non-human primates infected with monkeypox virus and rabbits infected with rabbitpox virus 6
  • Treatment with tecovirimat for 14 days resulted in statistically significant improvement in survival compared to placebo in animal models 6
• Other potential antivirals include cidofovir and brincidofovir, though these are considered second-line options 2, 4

Special Populations

• Patients with immunodeficiencies are at higher risk for progressive disease and should be monitored closely 3
• Pregnant women with monkeypox require careful management due to potential risk of fetal transmission 3

Complications

• Potential complications include:
  • Secondary bacterial infections of skin lesions 3
  • Scarring after healing of lesions 1
  • Rare but serious complications such as encephalitis or pneumonia 2
  • In severe cases, particularly in immunocompromised individuals, progressive necrosis similar to progressive vaccinia can occur 3

Prevention

• Vaccination:
  • Newer generation smallpox vaccines (JYNNEOS) may be beneficial for monkeypox prevention 2
  • First-generation smallpox vaccines held in national reserves are not recommended as they do not meet current safety standards 2
• Infection control measures:
  • Isolation of infected individuals to prevent transmission 3
  • Contact tracing for exposed individuals 7
  • Proper hand hygiene and personal protective equipment for healthcare workers 3

Management Algorithm

1. Diagnosis:

   • Obtain samples from skin lesions for PCR testing 2
   • Consider epidemiological factors and clinical presentation 1

2. Risk Assessment:

   • Evaluate for risk factors for severe disease (immunocompromise, pregnancy, young age) 3
   • Assess extent of lesions and systemic symptoms 2

3. Treatment Decision:

   • For mild disease with limited lesions and no systemic illness: supportive care only 5
   • For severe disease (extensive lesions, systemic illness) or high-risk patients: consider tecovirimat 6
   • For ocular involvement: urgent ophthalmology consultation 3

4. Infection Control:

   • Implement isolation until all lesions have crusted over and new skin has formed 3
   • Use contact precautions to prevent secondary transmission 3

Common Pitfalls and Caveats

• Misdiagnosis as other vesicular rashes (chickenpox, herpes) can delay appropriate management 2
• Failure to recognize atypical presentations, especially in the 2022 outbreak where lesions may be localized to genital areas 1
• Inappropriate use of antibiotics without evidence of bacterial superinfection 4
• Inadequate infection control measures leading to secondary transmission 3
• Delay in initiating antiviral therapy in high-risk individuals, as animal studies show better outcomes with earlier treatment 6

Remember that monkeypox is typically self-limiting in immunocompetent individuals, but early recognition and appropriate management are essential to prevent complications and transmission to others 2, 1.