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EMERGENCY
PREPAREDNESS

Monkeypox:

What Bexar County Doctors Need to Know

By Junda Woo, MD, MPH, and Anita K. Kurian, MBBS, MPH, DrPH

NOTE: THIS IS A RAPIDLY EVOLVING RESPONSE. THE INFORMATION BELOW WAS UP-TO-DATE ON AUG. 2, 2022.

The United States now leads the world in • Screening: While 98% of cases to date are sion should be collected, using synthetic
monkeypox cases, with more than 6,300 of the among men who have sex with men, risk is (non-cotton) swabs, preferably from differ-
25,391 cases worldwide. Dallas has the most based on behaviors and exposures, not sex- ent locations on the body or from lesions
cases in Texas, followed by Houston, Austin, ual orientation. A heterosexual, cisgender that differ in appearance. It is not necessary
and then San Antonio, which has 13 cases as woman with recent syphilis and gonorrhea to unroof the lesion. Co-infections are pos-
of this writing. is at greater risk than a gay couple in a mu- sible, so also test for other potential infec-
From now on, monkeypox will belong in tually exclusive relationship. Thus a good tions as appropriate. Clinical care can begin
our differential diagnosis of herpes and other sexual history is a key element of your based on a positive orthopoxvirus result
unexplained rashes, especially when vesicular, screening, and will be more fruitful with the and should not wait on additional viral
pustular or nodular. For the generalist, here is use of nonjudgmental, neutral language, characterization testing.
a quick primer by public health. without assumptions about sexual orienta-
tion or behaviors. The CDC recommends • Management of infection: Supportive care
• Microbiology: Monkeypox is an Orthopox the 5 P’s as a mnemonic: Partners, Practices, includes maintenance of adequate fluid bal-
virus from the same family as variola virus Protection from STIs, Past history of STIs ance, pain management, and treatment of
(smallpox) and vaccinia, and a different and Pregnancy intention. any bacterial superinfection. Give anticipa-
virus family than varicella virus (chicken- tory guidance and address symptoms early
pox). It was discovered in 1958, and the first • Symptoms occur after an incubation period to prevent hospitalizations, for instance
human case was identified in 1970. The fa- of 1-3 weeks. There is often but not always through antihistamines and calamine lotion
tality rate was 1%-10% in previous out- a prodrome of fever, headache, lym- for itching, over-the-counter and prescrip-
breaks, but is lower with the current phadenopathy, and significant fatigue. After tion mouthwashes for mucositis, sitz baths
outbreak. The animal reservoir is unknown 1-4 days, a rash appears. (Lesion photos are and topical anesthetics for pain, and stool
but is likely small mammals. available on the CDC website.) Lesions softeners for proctitis. For people with se-
progress over 2-4 weeks from macules to vere disease or at high risk for severe disease,
• Transmission most commonly occurs papules, vesicles, pustules, and then scabs. tecovirimat (TPOXX) treatment is avail-
through direct contact with an infectious Enanthem are also possible. The patient re- able under a CDC Investigational New
rash, scabs or bodily fluids. Transmission is mains infectious until all scabs have fallen Drug protocol. Doctors can call Metro
also possible through respiratory secretions off and fresh skin is evident. While most Health’s Epidemiology unit at 210-207-
during prolonged, face-to-face contact of people do not need hospitalization, in some 8876 or email MpoxConsult@ sananto-
at least 3 hours; contact with fomites such people, pain from genital, anal and oropha- nio.gov to obtain tecovirimat. A provider
as bed linens; vertical transmission through ryngeal lesions can be severe enough to in- prescription will be needed, and ordering
the placenta; and scratches, bites or other terfere with bodily functions. providers must complete all CDC proto-
contact with an infected animal. People cols and requirements.
without symptoms cannot spread the virus • Diagnosis: Testing is available through • Education: Let patients know that the pub-
to others, but lesions may not always be no- commercial labs including LabCorp and lic health department will be reaching out
ticed if present in the mouth, rectum or Quest with CPT code 87593. A swab of to them. Advise patients to isolate from
vagina. The Centers for Disease Control & the lesion from any part of the body is ac- people and pets until all lesions have re-
Prevention (CDC) recommends abstain- ceptable. PPE for specimen collection con- solved, the scabs have fallen off, and a fresh
ing from sex for 8 weeks after an infection sists of eye protection, a disposable gown, layer of intact skin has formed. In a shared
ends, due to possible persistence in semen gloves and a mask (currently the CDC household, they can reduce transmission to
or vaginal fluids. specifies an N95, out of an abundance of others by using separate linens, clothing,
caution). Note that two swabs from each le- drinking glasses and eating utensils, wearing

32 SAN ANTONIO MEDICINE • September 2022