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Monkeypox

Mpox—A Rapidly Evolving Disease

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JAMA Dermatology

Published Online: February 9, 2023

Special Communication

Article Information and Disclosures

Edward W. Cowen, MD, MHSc¹;

Eric R. Tkaczyk, MD, PhD^2,3;

Scott A. Norton, MD, MPH, MSc⁴;

Kieron S. Leslie, MBBS, DTM&H⁵

Author Affiliations

¹Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
²Dermatology Service and Research Service, Department of Veterans Affairs, Nashville, Tennessee
³Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
⁴Department of Dermatology, George Washington University, Washington, DC
⁵Department of Dermatology, University of California, San Francisco

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Abstract

The 2022 mpox outbreak has rapidly emerged onto the global medical scene while the world continues to grapple with the COVID-19 pandemic. Unlike COVID-19, however, most patients with mpox present with skin findings, the evolving clinical presentation of which may be mistaken for other common skin diseases, particularly sexually transmitted infections. This Special Communication provides an overview of the evolution of mpox skin findings from its initial description in humans in 1970 to the present-day multinational outbreak.

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Article Information

Accepted for Publication: January 10, 2023.

Published Online: February 9, 2023. doi:10.1001/jamadermatol.2023.0041

Corresponding Author: Edward W. Cowen, MD, MHSc, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 10 Center Dr, Bethesda, MD 20892 (cowene@mail.nih.gov).

Author Contributions: Dr Cowen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cowen, Tkaczyk, Leslie.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Obtained funding: Tkaczyk.

Administrative, technical, or material support: Tkaczyk, Leslie.

Supervision: Cowen, Tkaczyk.

Conflict of Interest Disclosures: Dr Tkaczyk reported receiving grants from the US Department of Veterans Affairs and National Institutes of Health during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was supported by the Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases and a Career Development Award from US Department of Veterans Affairs Clinical Sciences R&D Service (IK2 CX001785).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient in eFigure 2 for granting permission to publish this information. We also thank Madeline Marks, BS, for her assistance composing Figure 1; Monica Valentin, MD, and Christen Samaan, MD, for assistance composing the Table; and Jason Zucker, MD, for additional clinical images. The individuals were not compensated for these contributions.

References

Reed KD , Melski JW , Graham MB , et al. The detection of monkeypox in humans in the Western Hemisphere. N Engl J Med. 2004;350(4):342-350. doi:10.1056/NEJMoa032299 PubMed Google Scholar Crossref

Sale TA , Melski JW , Stratman EJ . Monkeypox: an epidemiologic and clinical comparison of African and US disease. J Am Acad Dermatol. 2006;55(3):478-481. doi:10.1016/j.jaad.2006.05.061 PubMed Google Scholar Crossref

Reynolds MG , Yorita KL , Kuehnert MJ , et al. Clinical manifestations of human monkeypox influenced by route of infection. J Infect Dis. 2006;194(6):773-780. doi:10.1086/505880 PubMed Google Scholar Crossref

Happi C , Adetifa I , Mbala P , et al. Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus. PLoS Biol. 2022;20(8):e3001769. doi:10.1371/journal.pbio.3001769 PubMed Google Scholar Crossref

von Magnus P , Andersen EK , Petersen KB , Birch-Andersen A . A pox-like disease in cynomolgus monkeys. Acta Pathologica Microbiologica Scandinavica. 1959;46(2):156-176. doi:10.1111/j.1699-0463.1959.tb00328.x Google Scholar Crossref

Gessain A , Nakoune E , Yazdanpanah Y . Monkeypox. N Engl J Med. 2022;387(19):1783-1793. doi:10.1056/NEJMra2208860 PubMed Google Scholar Crossref

Bunge EM , Hoet B , Chen L , et al. The changing epidemiology of human monkeypox—a potential threat? a systematic review. PLoS Negl Trop Dis. 2022;16(2):e0010141. doi:10.1371/journal.pntd.0010141 PubMed Google Scholar Crossref

Tarín-Vicente EJ , Alemany A , Agud-Dios M , et al. Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. Lancet. 2022;400(10353):661-669. doi:10.1016/S0140-6736(22)01436-2 PubMed Google Scholar Crossref

Gigante CM , Korber B , Seabolt MH , et al. Multiple lineages of monkeypox virus detected in the United States, 2021-2022. Science. 2022;378(6619):560-565. doi:10.1126/science.add4153 PubMed Google Scholar Crossref

Centers for Disease Control and Prevention. Additional testing of biopsy tissues in severe mpox infections. Updated October 31, 2022. Accessed January 19, 2023. https://www.cdc.gov/poxvirus/monkeypox/clinicians/prep-collection-specimens/biopsies.html

Pittman R , Martin JW , Kingebeni PM , et al. Clinical characterization of human monkeypox infections in the Democratic Republic of the Congo. medRxiv. Preprint posted online May 29, 2022. doi:10.1101/2022.05.26.22273379 Google Scholar

Kozlov M . How deadly is monkeypox? what scientists know. Nature. 2022;609(7928):663. doi:10.1038/d41586-022-02931-1 PubMed Google Scholar Crossref

World Health Organization. 2022 Mpox (monkeypox) outbreak: global trends. Updated December 27, 2022. Accessed December 27, 2022. https://worldhealthorg.shinyapps.io/mpx_global/

Likos AM , Sammons SA , Olson VA , et al. A tale of two clades: monkeypox viruses. J Gen Virol. 2005;86(Pt 10):2661-2672. doi:10.1099/vir.0.81215-0 PubMed Google Scholar Crossref

Jezek Z , Fenner F . Human monkeypox. Monogr Virol. 1988;17:1-140.Google Scholar Crossref

Tecovirimat for treatment of monkeypox virus. ClinicalTrials.gov identifier: NCT05559099. Updated October 27, 2022. Accessed January 19, 2023. https://clinicaltrials.gov/ct2/show/NCT05559099

McNeil AJ , House DW , Mbala-Kingebeni P , et al. Counting monkeypox lesions in patient photographs: limits of agreement of manual counts and artificial intelligence. J Invest Dermatol. Published online September 15, 2022. doi:10.1016/j.jid.2022.08.044 PubMed Google Scholar Crossref

Thornhill JP , Barkati S , Walmsley S , et al; SHARE-net Clinical Group. Monkeypox virus infection in humans across 16 countries—April-June 2022. N Engl J Med. 2022;387(8):679-691. doi:10.1056/NEJMoa2207323 PubMed Google Scholar Crossref

Rojek A , Dunning J , Olliaro P . Monkeypox: how will we know if the treatments work? Lancet Infect Dis. 2022;22(9):1269-1270. doi:10.1016/S1473-3099(22)00514-X PubMed Google Scholar Crossref

Mols JF , Ledent E , Heineman TC . Sampling of herpes zoster skin lesion types and the impact on viral DNA detection. J Virol Methods. 2013;188(1-2):145-147. doi:10.1016/j.jviromet.2012.12.013 PubMed Google Scholar Crossref

Centers for Disease Control and Prevention. Tips for adequate collection of a lesion specimen from a suspect monkeypox virus case. Accessed December 27, 2022. https://www.cdc.gov/poxvirus/monkeypox/pdf/mpox-adequatespecimencollection_508.pdf

Mendoza R , Petras JK , Jenkins P , et al. Monkeypox virus infection resulting from an occupational needlestick—Florida, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(42):1348-1349. doi:10.15585/mmwr.mm7142e2 PubMed Google Scholar Crossref

Carvalho LB , Casadio LVB , Polly M , et al. Monkeypox virus transmission to healthcare worker through needlestick injury, Brazil. Emerg Infect Dis. 2022;28(11):2334-2336. doi:10.3201/eid2811.221323 PubMed Google Scholar Crossref

Del Río García V , Palacios JG , Morcillo AM , Duran-Pla E , Rodríguez BS , Lorusso N . Monkeypox outbreak in a piercing and tattoo establishment in Spain. Lancet Infect Dis. 2022;22(11):1526-1528. doi:10.1016/S1473-3099(22)00652-1 PubMed Google Scholar Crossref

Scotti B , Piraccini BM , Gaspari V . Hypertrophic verrucous lesions after monkeypox virus infection. Lancet Infect Dis. Published online October 26, 2022. doi:10.1016/S1473-3099(22)00695-8 PubMed Google Scholar Crossref

Miller MJ , Cash-Goldwasser S , Marx GE , et al; CDC Severe Monkeypox Investigations Team. Severe monkeypox in hospitalized patients—United States, August 10-October 10, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(44):1412-1417. doi:10.15585/mmwr.mm7144e1 PubMed Google Scholar Crossref

Centers for Disease Control and Prevention. 2022 Mpox outbreak global map. Updated December 22, 2022. Accessed December 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html

Golden MR , Wasserheit JN . Monkeypox—a sobering sentinel for pandemic preparedness and sexual health system capacity. N Engl J Med. 2022;387(20):1826-1829. doi:10.1056/NEJMp2212262 PubMed Google Scholar Crossref

Perez Duque M , Ribeiro S , Martins JV , et al. Ongoing monkeypox virus outbreak, Portugal, 29 April to 23 May 2022. Euro Surveill. 2022;27(22):2200424. doi:10.2807/1560-7917.ES.2022.27.22.2200424 PubMed Google Scholar Crossref

Yinka-Ogunleye A , Aruna O , Dalhat M , et al; CDC Monkeypox Outbreak Team. Outbreak of human monkeypox in Nigeria in 2017-18: a clinical and epidemiological report. Lancet Infect Dis. 2019;19(8):872-879. doi:10.1016/S1473-3099(19)30294-4 PubMed Google Scholar Crossref

Angelo KM , Smith T , Camprubí-Ferrer D , et al; GeoSentinel Network Collaborators. Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: a cross-sectional study. Lancet Infect Dis. 2022;S1473-3099(22)00651-X. doi:10.1016/S1473-3099(22)00651-X PubMed Google Scholar Crossref

Rao AK , Petersen BW , Whitehill F , et al. Use of JYNNEOS (smallpox and monkeypox vaccine, live, nonreplicating) for preexposure vaccination of persons at risk for occupational exposure to orthopoxviruses: recommendations of the Advisory Committee on Immunization Practices—United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(22):734-742. doi:10.15585/mmwr.mm7122e1 PubMed Google Scholar Crossref

JYNNEOS. Package insert. Updated April 2022. Accessed December 27, 2022. https://www.fda.gov/media/131078/download

Centers for Disease Control and Prevention. JYNNEOS vaccine. Updated December 22, 2022. Accessed December 27, 2022. https://www.cdc.gov/poxvirus/monkeypox/interim-considerations/jynneos-vaccine.html

Payne AB , Ray LC , Kugeler KJ , et al. Incidence of monkeypox among unvaccinated persons compared with persons receiving ≥1 JYNNEOS vaccine dose—32 US jurisdictions, July 31-September 3, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(40):1278-1282. doi:10.15585/mmwr.mm7140e3 PubMed Google Scholar Crossref

Centers for Disease Control and Prevention. Interim clinical considerations for use of JYNNEOS and ACAM2000 vaccines during the 2022 US mpox outbreak. Updated October 19, 2022. Accessed December 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/vaccines/vaccine-considerations.html

Webb E , Rigby I , Michelen M , et al. Availability, scope and quality of monkeypox clinical management guidelines globally: a systematic review. BMJ Glob Health. 2022;7(8):e009838. doi:10.1136/bmjgh-2022-009838 PubMed Google Scholar Crossref

Centers for Disease Control and Prevention. Guidance for tecovirimat use. Updated September 15, 2022. Accessed December 23, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/Tecovirimat.html

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