The Exchange

Commentary and Observations from
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Monkeypox: Clinical Recognition

Monkeypox: Clinical Recognition

As healthcare providers, we have been alerted by local public healthcare agencies, healthcare institutions, the internet, and news sources to be vigilant for patients presenting with a rash and illness consistent with monkeypox. Monkeypox typically has a 7- to 14-day incubation period, but a range of 5 to 21 days has been reported.

The initial symptoms that define the prodromal period mimic a flu-like illness and include fever, malaise, headache, and weakness. A sign that distinguishes monkeypox from smallpox is lymphadenopathy, which may be generalized or localized, and includes cervical, axillary, and inguinal presentations. Soon after the prodromal period, the rash develops with staged progression from macular to papular, to vesicular, to pustular, and then with the lesions scabbing over before resolving. This entire process occurs over 2 to 3 weeks. In monkeypox, the lesions appear at the same time, helping to distinguish the disease from varicella (chickenpox), in which lesions appear in "crops." To further help distinguish the disease, the CDC website has photos of the rash in the various stages of presentation and on a variety of skin colors. Some other key characteristics of monkeypox are fever prior to rash onset, deep-seated lesions with umbilication, pain prior to scabbing, and location in the mouth and on the palms and soles. The person is contagious from the onset of the enanthem through resolution of scabbing.

The severity of illness depends on the patient's general health status and comorbid factors, the source of the infection, and the region of viral genus origin—namely, whether it is Western African vs Central African. Central African monkeypox virus strains tend to be more severe and carry a higher mortality rate with documented human-to-human transmission capability.

Epidemiologic data should be strongly considered in the differential diagnoses of persons presenting with rash illnesses within the past 21 days. Questions should be asked to determine if the patient has had exposure to a person with a similar rash or a confirmed/probable monkeypox diagnosis, close or intimate in-person contact with a person in a social network experiencing monkeypox infections (such as men who have sex with men), travel to a country with confirmed monkeypox infections or endemicity. They should also be asked about contact with wild animals or exotic pets (dead or alive) that are an African endemic species—including if they have used a product from such an animal.

If you have a patient with suspected monkeypox, your local health departments and infectious disease experts should be consulted to determine testing, potential treatment, and isolation or quarantine guidelines, as well as contact tracing when needed.


Filed under: Infectious Diseases, Public Health

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