Avoid getting caught off guard if the latest virus swings through your ED.
Medicine changed when the COVID-19 pandemic hit in 2020. Now in 2022, we are yet again facing another virus that has the potential to change the practice of Emergency Medicine (EM) – Monkeypox (MPX).
MPX was endemic to Western and Central Africa for many decades, but it first made its appearance in the United States in 2003, an outbreak that was quickly contained through contact tracing and smallpox vaccine administration to close contacts. However, in 2022, it returned with a higher presence and prevalence. [1, 2] As of September 2022, over 64,000 cases, including 20 deaths, have been confirmed by the Centers for Disease Control and Prevention (CDC). 
While most MPX cases will improve and resolve with supportive measures, we expect many patients to seek help in the acute setting, including in our emergency departments. In continuing to read this article, we hope that you become familiar with the clinical presentation, diagnostic testing, and management/treatment options for MPX in the emergency department (ED).
In Africa, Monkeypox is known to be primarily transmitted through contact with animals; however, it can also spread from person-to-person. Transmission of MPX is now mostly linked to close contact with an infected person. However, different transmission modes have been described, including skin-to-skin contact (particularly with an MPX lesion), respiratory droplets, direct contact with contaminated objects and pregnant mother to fetus (though rare). 
Infection during sex is the most common form of transmission described thus far in the United States and Europe. The CDC found that most cases have been in individuals self-identifying as gay, bisexual or men who have sex with men.  The incubation period varies from seven- to 14-days but can be up to 21 days from exposure. 
What are some clinical features to trigger consideration of monkeypox? Symptoms typically begin with a viral prodrome that lasts one- to-five-days, including fever, lymphadenopathy, chills, headache and myalgias.  Patients develop characteristic skin lesions in variable and unpredictable numbers, locations and characters. Genital and anorectal involvement is common. Lesions are painful and classically develop centrifugally, appearing in crops at various phases of development.
They go through four typical stages in one- to two-day increments: macular, papular, vesicular to pustular. Lesions then progress to scabs for five- to seven-days and eventually desquamate and fall off in one- to two-weeks. Lesions are typically painful until healing with scabbing occurs. Only once all the scabs have fallen off and fresh skin is visible is the person no longer contagious. 
Safety for yourself and other patients is important when managing a patient with MPX. First, and foremost, Personal Protective Equipment (PPE) for standard contact and droplet precautions is recommended for any healthcare worker managing a patient with suspected MPX. As previously discussed, the risk of aerosolized transmission is present, and, therefore, the CDC recommends airborne precautions as well, meaning respirator plus eye protection (or PAPR), disposable gloves and gown. 
Evaluation of MPX should be initiated with any clinical suspicion based on history that includes recent travel to endemic areas, exposure to infected individuals and sexual history. A full skin examination should be performed, including oral mucosa and genitals. Alternative diagnoses include chickenpox and smallpox; however, the most distinguishing characteristic of MPX is the lymphadenopathy accompanied by a slow progression of the lesions. 
The diagnosis of MPX requires testing of skin or mucosal lesions for viral DNA PCR, like the technology used to diagnose COVID. It requires two swab specimens from a minimum of three lesions using sterile, dry polyester, nylon or Dacron swabs:
- Gently sanitize the area with an alcohol wipe and let dry
- Unroof the lesion with the flat portion of a scalpel blade (for genital lesions, you can aggressively swab the lesion without unroofing it)
- Swab the base of the lesion
- Repeat for a second lesion, ideally from another body site.
There are some laboratory findings as well, which include low BUN, elevated transaminase levels, hypoalbuminemia and thrombocytopenia. In any suspected MPX case requiring sample collection, please contact the CDC and your state health department.
Management is largely supportive care through hydration, pain control and treating/preventing complications. MPX symptoms typically resolve over two- to four-weeks, but severe illness has been documented. Complications include secondary bacterial skin infections, pneumonitis, ocular complications and encephalitis. In addition to hydration and pain control, other treatments include antibiotics for secondary skin infections or conjunctivitis and respiratory support for pneumonitis.
Those at higher risk for severe disease and poor outcomes include children, young adults, individuals not immunized against smallpox, and those who are immunocompromised.  These patients may need more than supportive care, particularly immunocompromised patients. While no medications are approved to treat MPX, it is thought that medications effective against smallpox could also be efficacious against MPX given the similarities between the two viruses.
These medications include Brincidofovir, Cidofovir, Tecovirimat and Vaccinia Immune Globulin Intravenous (VIGIV). While Brincidofovir, Cidofovir and Tecovirimat have shown efficacy against MPX in animals, no studies have shown effectiveness for VIGIV against MPX.  Patients should be informed about the lack of scientific evidence and clinical trials. Each of these medications comes with several side effects, and as such, these treatments should only be considered for high-risk patients after a shared decision-making conversation.
To keep or not to keep? Admission for these patients is like any other illness. Admission is needed for patients who cannot tolerate PO, have uncontrolled pain or require IV medications for complications. Consider consultation with an infectious disease specialist and local/state/federal health authorities to determine an appropriate disposition in some cases.
Last, but certainly not least, prevention is a key part of our practice as EM physicians. Patients should be advised to quarantine until all lesions have resolved, scabs have fallen off, and new skin has formed. This includes isolation from mammalian animals as well. If patients cannot quarantine, they should be advised to wear surgical-grade masks, long sleeves, and pants to prevent human contact with their lesions.
Until all symptoms have fully resolved, patients must refrain from sharing items that have been worn or touched, disinfect anything touched by a lesion, avoid crowds, and wash their hands with soap and water or alcohol-based hand sanitizer.  Another key component to prevention is postexposure prophylaxis (PEP), optimally given within four days of exposure, although can be considered up to 14 days postexposure.
The CDC has guidelines to determine the ‘degree of exposure’ and guide EM physicians in whom to prescribe PEP.  Jynneos and ACAM2000 are two vaccines available for PEP and, when properly administered, are effective at preventing disease and/or reducing severity.  Should the need for PEP against MPX occur, please call the CDC Emergency Operations Center at 770-388-7100.
While this MPX outbreak was unexpected, we hope to better prepare EM clinicians for possible cases in their ED. There are still a lot of unknowns regarding this virus, including transmission methods, treatment, etc. However, we do know is that we must educate ourselves and our patients to treat them and prevent transmission. For the most up-to-date information, visit the CDC page for MPX.  Clinicians must remain vigilant for updates and recommendations from local, state and federal health authorities as more is learned about this outbreak.
 About monkeypox. Centers for Disease Control and Prevention. Updated July 22, 2021. Accessed September 18, 2022. https://www.cdc.gov/poxvirus/monkeypox/about.html
 Centers for Disease Control and Prevention. Multistate outbreak of monkeypox—Illinois, Indiana, and Wisconsin, 2003. MMWR Morb Mortal Wkly Rep, 2003 5253740.
 2022 Monkeypox outbreak global map. Centers for Disease Control and Prevention. Updated September 21, 2022. Accessed September 22, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/worldmap.html
 How it spreads. Centers for Disease Control and Prevention. Updated July 29, 2022. Accessed September 19, 2022. https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html
 Multi-country monkeypox outbreak in non-endemic countries. Published May 21, 2022. Geneva, Switzerland: World Health Organization. Accessed May 23, 2022. https://www.who.int/ emergencies/disease-outbreak-news/item/2022-DON385
 American College of Emergency Physicians. Monkeypox field guide. 2022. American College of Emergency Physicians. Accessed September 19, 2022. https://www.acep.org/monkeypox-field-guide/cover-page/
 Gregory D. Huhn, Audrey M. Bauer, Krista Yorita, Mary Beth Graham, James Sejvar, Anna Likos, Inger K. Damon, Mary G. Reynolds, Matthew J. Kuehnert, Clinical Characteristics of Human Monkeypox, and Risk Factors for Severe Disease, Clinical Infectious Diseases, Volume 41, Issue 12, 15 December 2005, Pages 1742–1751, https://doi.org/10.1086/498115
 Clinical recognition. Centers for Disease Control and Prevention. Updated August 23, 2022. Accessed September 19, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html.
 Infection control monkeypox in healthcare settings. Centers for Disease Control and Prevention. Updated August 11, 2022. Accessed September 22, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html
 Treatment information for healthcare professionals. Centers for Disease Control and Prevention. Updated September 15, 2022. Accessed September 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
 Isolation and Prevention Practices. Centers for Disease Control and Prevention. Updated August 2, 2022. Accessed September 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/isolation-procedures.html
 Monitoring Persons Exposed. Centers for Disease Control and Prevention. Updated September 15, 2022. Accessed September 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/monitoring.html
 Vaccine Considerations. Centers for Disease Control and Prevention. Updated August 22, 2022. Accessed September 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/health-departments/vaccine-considerations.html.
 Monkeypox. Centers for Disease Control and Prevention. Updated September 7, 2022. Accessed September 23, 2023. https://www.cdc.gov/poxvirus/monkeypox/index.html