A few days ago, the first instance of the virus was discovered in India, causing residents and the government to be concerned. This article provides awareness about monkeypox, also its management, diagnosis and preventive measures to be taken during this disease.

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Monkeypox history

Monkeypox was first recorded in India on 14 July 2022, with over 6,000 cases across 60 nations and three fatalities. After the detection of the first case of monkeypox on 15 July, the Ministry of Health released management guidelines for the illness. Due to its rapid spread and severe symptoms, the monkeypox virus sparked concern in a number of nations.

As soon as the first instance of the monkeypox virus was identified in India, the Centre issued advice for state governments and overseas tourists, advising everyone to:

"Avoid contact with infected persons."

In addition, the federal government has advised that: If you are in an area where monkeypox has been found, you should seek medical attention. If you have been in touch with a person who has monkeypox, it is also recommended that you visit a medical professional immediately.

The ICMR claimed:

"To aid in the nation's readiness for Monkey Pox detection, 15 Virus Research & Diagnostic Laboratories, which are geographically dispersed and strategically placed, have been trained in the diagnostic test by ICMR-NIV, Pune."

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Salient features of Indian guidelines 

Host

The natural reservoir is yet unknown. However, certain rodents (including rope squirrels, tree squirrels, Gambian pouched rats, and dormice) and non-human primates are known to be naturally susceptible to the monkeypox virus.

Incubation period

Monkeypox has an incubation period (interval from infection to onset of symptoms) usually from 6 to 13 days but can range from 5 to 21 days. Period of communicability: 1-2 days before the rash until all the scabs fall off/get subsided.

Mode of transmission

1. Human-to-human transmission is known to occur primarily through large respiratory droplets which generally requiring prolonged close contact. It can be transmitted through direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens of an infected person.
2. Animal-to-human transmission: may occur by bite/scratch of infected animals like small mammals including rodents (rats, squirrels) and non-human primates (monkeys, apes) or through bush meat preparation.

Suspected case

A person of any age who has a history of travel to affected countries within the last 21 days
presenting with an unexplained acute rash AND one or more of the following signs or symptoms

• Swollen lymph nodes
• Fever
• Headache
• Body aches
• profound weakness

Probable case
A person meeting the case definition for a suspected case, which is a clinically compatible illness and has an epidemiological link (face-to-face exposure, including health care workers without appropriate PPE; direct physical contact with skin or skin lesions, including sexual contact; or contact with contaminated materials such as clothing, bedding or utensils is suggestive of a strong epidemiological link).

Confirmed case

A case which is laboratory confirmed for monkeypox virus (by detection of unique sequences of viral DNA either by polymerase chain reaction (PCR) and/or sequencing).

Clinical features

Monkeypox is usually a self-limited disease with symptoms lasting from 2 - 4 weeks. Severe cases occur more commonly among children and they are related to the extent of virus exposure, patient health status and nature of complications.

The extent to which asymptomatic infection occurs is unknown. The case fatality ratio of monkeypox has historically ranged from 0 to 11% in the general population and has been higher among young children. In recent times the case fatality ratio has been around 3-6%.

Common symptoms and signs

1. Prodrome (0-5 days)

1. Fever
2. Lymphadenopathy

• Typically occurs with fever onset
• Periauricular, axillary, cervical or inguina
• Unilateral or bilateral

3. Headache, muscle aches, exhaustion
4. Chills and/or sweats
5. Sore throat and cough

2. Skin involvement (rash)

• Usually begins within 1 to 3 days of fever onset, lasting for around 2-4 weeks.
• Deep-seated, well-circumscribed and often develop umbilication.
• Lesions are often described as painful until the healing phase whenever they become itchy (in the crust stage)
• Stages of rash (slow evolution)

1. Enanthem- first lesions on tongue and mouth
2. Macules start from the face and spread to arms, legs, palms, and soles (centrifugal distribution), within 24 hours
3. The rash goes through a macular, papular, vesicular also pustular phase. Classic lesion is vesicopustular
4. Involvement by area- face (98%), palms and soles (95%), oral mucous membranes (70%), genitalia (28%), conjunctiva (20%). Mostly, skin rashes are more apparent on the limbs and face than on the trunk. Notably, the genitalia can be involved and can be a diagnostic dilemma in the STD population
5. By 3rd day lesions gain to papules.
6. By the 4th to 5th day, lesions become vesicles (raised and fluid-filled).
7. By 6th to 7th-day lesions evolve pustular, sharpy raised, filled with opaque fluid, firm and deep-seated.
8. May umbilicate or they become confluent.
9. And by the end of 2nd week, they dry up and crust.
10. Scabs remain for a week before falling off.
11. The lesion heals with hyperpigmented atrophic scars, hypopigmented atrophic scars, patchy alopecia, hypertrophic skin scarring and contracture or deformity of facial muscles following the healing of ulcerated facial lesions.
12. A notable predilection for palm and soles is characteristic of monkeypox.

• The skin manifestation depends on vaccination status, age, nutritional status, and associated HIV status. Monkeypox chiefly occurs in communities where there is often a high background prevalence of malnutrition, parasitic infections, and other significant heath-compromising conditions, any of which could impact the prognosis of a patient with MPX.
• The total lesion burden at the apex of the rash can be quite high (>500 lesions) / relatively slight (<25).

Differential diagnosis

Varicella (Chickenpox), disseminated herpes zoster, disseminated herpes simplex, measles, chancroid, secondary syphilis, hand foot mouth disease, infectious mononucleosis, molluscum contagiosum.

Complications

• Secondary infections
• Pneumonia, sepsis, encephalitis
• Corneal involvement (may lead to loss of vision)

Diagnosis

Clinical samples to be collected Traveller from outbreak /endemic region or community transmission

Asymptomatic

1. Observe for the development of any signs and symptoms for 21 days post-exposure.
2. If signs and symptoms develop, collect specimens as per the duration of illness as mentioned below.

Symptomatic

1. Rash phase

1. Lesion roof- with a scalpel or plastic scrapper collected in a plain tube
2. Lesion fluid with an intradermal syringe
3. Lesion base scrapings with sterile polyester swab collected in a plain tube
4. Lesion crust in a plain tube
5. NPS/OPS in dry plain tube [without any bacterial medium or VTM]
6. Blood collected in SSGT (4-5 ml)
7.  Blood collected in EDTA (2-3ml)
8. Urine in a sterile urine container (3-5ml)

2. Recovery phase

• Blood collected in SSGT (4-5 ml)
• Urine is a sterile urine container (3-5ml)

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Diagnostic modalities for monkeypox with ICMR NIV Pune

For the verification of monkeypox on the suspected clinical specimens:

PCR for Orthopoxvirus genus [Cowpox, Buffalopox, Camelpox, Monkeypox] will be accomplished. If the specimen will show positivity for the Orthopoxvirus, it would be further confirmed by Monkeypox-specific conventional PCR or real-time PCR for Monkeypox DNA Additionally, virus isolation and the Next Generation Sequencing of clinical samples (Miniseq and Nextseq) will be used for the definition of the positive clinical specimens.

Management

• Principles of management
• Patient isolation
• Protection of compromised skin and mucous membranes
• Rehydration therapy and Nutritional support
• Symptom alleviation
• Monitoring and treatment of complications

Patient isolation

1. Isolation of the patient in an isolation room of the hospital/ at home in a separate room with separate ventilation.
2. The patient to wear a triple-layer mask.
3. Skin lesions should be shielded to the best extent possible (e.g. long sleeves, long pants) to minimise the risk of contact with others.
4. Isolation is to be resumed until all lesions have resolved and scabs have completely fallen off.

Supportive management of monkeypox

Protection of compromised skin and mucous membranes

1. Skin rash

• Clean with simple antiseptic
• Mupironic acid/Fucidin
• Cover with light dressing if extensive lesion present
• Do not touch/ scratch the lesions
• In the case of secondary infection, relevant systematic antibiotics may be viewed. 

2. Genital ulcers- Sitz bath

3. Oral ulcers- Warm saline gargles/ oral topical anti-inflammatory gel

4. Conjunctivitis

• Usually, self-limiting
• Consult Ophthalmologist if symptoms persist or if there are pain/ visual disturbances

5. Rehydration therapy and nutritional support

• Encourage ORS or oral fluids
• Intravenous fluids if indicated
• Encourage a nutritious and adequate diet

6. Symptom alleviation

Fever

• Tepid sponging
• Paracetamol as required

Itching/Pruritus

• Topical Calamine lotion
• Antihistaminics

Nausea and vomiting- Consider anti-emetics

Headache/ malaise - Paracetamol and adequate hydration

7. Monitoring and treatment of complications
The patient should closely monitor for the appearance of any of the following signs during
the period of isolation:

• Pain in the eye or blurring of vision
• Shortness of breath, chest pain, difficulty in breathing
• Altered consciousness, seizure
• Decrease in urine output
• Poor oral intake
• Lethargy

In case any of the above symptoms occur, the patient should immediately contact a nearby healthcare facility/ specialist.

8. Preventive measures

1. Avoid contact with any materials, such as bedding, that have been in touch with a sick person.
2. Isolate infected patients from others.
3. Rehearse good hand hygiene after contact with infected animals or humans. For instance, washing your hands with soap and water or using an alcohol-based hand sanitiser.
4. Use proper personal protective equipment (PPE) when caring for patients.

9. Duration of isolation Procedures 

Affected individuals should avoid close contact with immunocompromised persons and pregnant women until all crusts are gone. Isolation protection should be continued until all lesions have resolved and a fresh layer of skin has formed.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.