IDAHO HEALTH ALERT NETWORK


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Message ID:   2079      Public Message
Subject:   Updated Guidance for Clinicians on Recognizing Monkeypox 8-4-22
Sent By:   PHD7 Date Sent:   8/4/2022 1:33:39 PM
Priority:   Advisory Status:   Sent (Delivered)
PHIN Specific Data:
Severity:   Moderate Delivery Time:   15 Minutes
PHIN Status:   Actual Message Type:   Alert
Sensitivity:   Non Sensitive Acknowledgement:   No
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Message Text:

The first case of Monkeypox in our health district was reported to Eastern Idaho Public Health on 8/3/2022.  This health alert was originally sent out on June 16, 2022, and resent today with updated information to increase awareness and information pertaining to Monkeypox. 

 

Updated Guidance for Clinicians on Recognizing Monkeypox

 

Clinicians should be aware that in the current monkeypox outbreak in the U.S, clinical cases may not be recognized and tested because of uncharacteristic features compared to historical outbreaks and cases.  Please review the clinical presentations and recommendations for clinicians below.

 

Clinical presentations of confirmed cases to date
Descriptions of classic monkeypox disease describe a prodrome including fever, lymphadenopathy, headache, and muscle aches followed by development of a characteristic rash culminating in firm, deep-seated, well-circumscribed and sometimes umbilicated lesions. The rash usually starts on the face or in the oral cavity and progresses through several synchronized stages on each affected area and concentrates on the face and extremities, including lesions on the palms and soles.

 

However, in the current outbreak, prodromal symptoms have not always occurred before the rash if they have occurred at all. In the U.S, all patients diagnosed with monkeypox have experienced a rash or enanthem. Although the characteristic rash has been observed, the rash has often begun in mucosal areas (i.e., genital, perianal, oral mucosa) and in some patients, the lesions have been scattered or localized to a specific body site and have not involved the face or extremities. [See images below.]

 

Some patients have presented with symptoms such as anorectal pain, tenesmus, and rectal bleeding which upon physical examination, have been found to be associated with visible perianal vesicular, pustular, or ulcerative skin lesions and proctitis. Unlike classic monkeypox disease, the lesions have sometimes been in different stages of progression on a specific anatomic site (e.g., vesicles and pustules existing side-by-side).

 

The clinical presentation of monkeypox may be similar to some STIs, such as syphilis, herpes, lymphogranuloma venereum (LGV), or other etiologies of proctitis. Clinicians should perform a thorough skin and mucosal (e.g., anal, vaginal, oral) examination for lesions consistent with monkeypox even if lesions consistent with those from more common infections (e.g., varicella zoster, syphilis, herpes) are observed.

 

Recommendations for Clinicians

·            Evaluate patients with rashes initially considered characteristic of more common infections (e.g., varicella zoster or sexually transmitted infections) for a concurrent monkeypox rash, especially if the person has epidemiologic risk factors for monkeypox infection.

·            Evaluate any individual presenting with perianal or genital ulcers, diffuse rash, or proctitis syndrome for STIs per the 2021 CDC STI Treatment Guidelines. Testing for STIs should be performed. The diagnosis of an STI does not exclude monkeypox, as a concurrent infection may be present. The clinical presentation of monkeypox may be similar to some STIs, such as syphilis, herpes, lymphogranuloma venereum (LGV), or other etiologies of proctitis.

·            Perform a thorough skin and mucosal (e.g., anal, vaginal, oral) examination for the characteristic vesiculo-pustular rash of monkeypox for individuals being evaluated for possible STI or who have one or more epidemiologic risk factors for monkeypox; this allows for detection of lesions the patient may not have been previously aware of.

·            Consider monkeypox testing for any patient who does not respond to STI treatment as expected.

·            Use appropriate infection prevention measures when collecting specimens for monkeypox evaluation.

·            Advise patients with prodromal symptoms (e.g., fever, malaise, headache) and one or more epidemiologic risk factors for monkeypox to self-isolate. If a rash does not appear within 5 days, the illness is unlikely to be monkeypox and alternative etiologies should be sought.

·            Any patient with illness meeting the suspect case definition (new characteristic rash OR meet one of the epidemiologic criteria and has high clinical suspicion for monkeypox) and who does not require hospitalization should be counseled to isolate at home, abstain from contact with other individuals and pets, and wear appropriate personal protective equipment (e.g., clothing to cover lesions, face mask) to prevent further spread until test results have been received.

·  Information for Healthcare Providers on Obtaining and Using TPOXX (Tecovirimat) for Treatment of Monkeypox can be found at https://www.cdc.gov/poxvirus/monkeypox/clinicians/obtaining-tecovirimat.html.

 

For More Information 

Contact the DHW Epidemiology Section at 208-334-5939 or Eastern Idaho Public Health 208-533-3152 if you have any questions or suspect a patient may have monkeypox.

·         Information for Healthcare Professionals 

·         Clinical Recognition of Monkeypox 

·         Monkeypox facts for people who are sexually active 

 

Images of Monkeypox

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Generalized monkeypox lesions are characteristically deep-seated, well-circumscribed, and often develop umbilication (A, B, C). Image A demonstrates both papulovesicular and pustular lesions in the same region of the body. Credits: Images A and B from NHS England High Consequence Infectious Diseases Network; image C from Reed KD, Melski JW, Graham MB et al. The detection of monkeypox in humans in the Western Hemisphere. Page 346. Copyright © 2004. Massachusetts Medical Society. Reprinted with permission. Please see lesion examples from Nigeria and Italy.