Diagnosis and Management of

Monkeypox in Primary Care

By: Dr Siti Syukriah binti Shaharudin
Supervisor: Dr Marina bt Masri (FMS KK Merlimau)
Outline

 Introduction
 Reservoir
 Route of transmissions
 Natural history of disease
 Diagnosis & Lab testing
 Management in Primary Care
 Infection and prevention control
Introduction
 Mpox is enveloped double
stranded DNA virus
 Family : Poxviridae
 Genus : Orthopoxvirus
 All orthopoxviruses are
antigenically related –
similar to smallpox &
cowpox
Genetic clades
 There are 2 phenotypically distinct clades of Mpox virus
through genomic sequencing
Reservoir
Routes of transmission

Through bite or scratch, bush meat

preparation, direct contact with blood, body
fluid, mucosal lesion of infected animals or
materials contaminated with the virus.
Natural history of the disease

Lymphadenopathy preceded
the onset of rash

Prodromal phase which

lasted 1-5 days
Important clinical features

++lymphadenopathy
Monkeypox rash progression
Monkeypox rash progression
Clinical disease

 Majority mild disease

 Can be asymptomatic

 Risk factors for severe illness include:-

 Children (neonates, young children)
 Pregnant women
 Immunodeficiency i.e HIV
 Invasive route of infection i.e animal bites, needle stick injury
 Congo basin clade variant
 Unvaccinated (smallpox vaccine)
Complications
 This disease may also affect oral mucous membrane,
genitalia, conjunctivae, and the cornea.

• Cellulitis Long term sequela include:

• Abscess
• Scarring
• Necrotizing soft tissue
infection
• Reduced skin
• Bronchopneumonia pigmentation
• Sepsis • Blindness – due to
• Encephalitis corneal ulcer/infection
• Infection of the cornea –
results in blindness
Infectivity period
 Infectivity period ranges from 1 (one) day before onset of
symptoms (prodrome period) up to 21 days after the
initial symptoms appear
 OR
 Until all skin lesions have formed scabs and no other
symptoms are present.
 Mpox is contagious until all scabs have fallen off and there
is intact skin underneath.
Online news article for Mpox in Msia
Clinical presentation for Mpox outbreak 2022

 Compared with typical mpox in endemic area, current global mpox

outbreak has been associated with concomitant HIV and STIs
involving primarily gay, bisexual and MSM.
 Clinical presentation differed from typical mpox, with fewer patient
experiencing prodrome symptoms and more experiencing genital
rashes.
 In a retrospective case series of 528 mpox infections from April to
June 2022 in 16 coutries, they concluded :-
 98% of patients were gay or bisexual men
 41% had HIV
 95% of the patients presented with rash
 Most common anatomical sites were anogenital area (73%), trunk, arms,
or legs (55%), face (25%), palms and soles (10%), and 41% had mucosal
lesions whereby they c/o anorectal pain, proctitis, tenesmus, diarrhoea,
pharyngitis, epiglottis, etc…
 Lesion in multiple phases present simultaneously
Differential diagnosis of maculopapular rash
Laboratory Investigation
Serology and antigen detection are not recommended for dx – cross
react with other orthopoxviruses

Optimal dx
specimen
Diagnostic confirmation
Case definition for the Mpox outbreak
 Suspected case
 A person who is a contact of a probable or confirmed mpox case in the
21 days before the onset of signs or symptoms, and who present with
any of the following: acute onset of fever, headache, myalgia, back pain,
profound weakness or fatigue.
 OR
 A person presenting since 1 Jan 2022 with unexplained acute skin rash,
mucosal lesion or lymphadenopathy. The skin rash may include single or
multiple lesions in the anogenital region or elsewhere on the body.
Mucosal lesions may include single or multiple oral, conjunctival, urethral,
penile, vaginal, or anorectal lesions. Anorectal lesions can also manifest as
anorectal inflammation (proctitis), pain and/or bleeding
 AND
 For which the following common causes of acute rash or skin lesions do
not fully explain the clinical picture i.e varicella zoster, herpes zoster,
measles, etc…
Case definition
 Probable case
 A person presenting with an unexplained acute skin rash, mucosal lesions or
lymphadenopathy.The skin rash may include single or multiple lesions in the
anogenital region or elsewhere on the body. Mucosal lesions may include
single or multiple oral, conjunctival, urethral, penile, vaginal, or anorectal
lesions. Anorectal lesions can also manifest as anorectal inflammation
(proctitis), pain and/or bleeding.
 AND
 One or more of the following:
 Has an epidemiological link to a probable or confirmed case of Mpox in the last 21
days before symptoms onset;
 Has multiple and/or casual sexual partners, either bisexual or MSM, in the past 21
days before symptoms onset;
 Has detectable level of anti-orthopoxvirus IgM antibody (during the period of 4-56
days after rash onset; or a four-fold rise in IgG antibody titre based on acute (up to
5-7 ) and convalescent (day 21 onwards) sample; in the absence of a recent
smallpox/mpox vaccination or other known exposure to anti-orthopoxvirus IgM
antibody;
 Has a positive test result for orthopoxviral infection (e.g OPXV-specific PCR
without mpox virus-specific PCR or sequencing)
Case definition
 Confirmed case
 A person with laboratory confirmed mpox virus infection of unique
sequences of viral DNA by real-time PCR and/or sequencing.

 Discarded case
 A suspected or probable case for which lab testing of lesion fluid,
skin specimens or crusts by PCR and/or sequencing is negative for
mpox virus.
 A retrospectively detected probable case for which lesion
testing can no longer be adequately performed and no other
specimen is found PCR positive , would remain as a probable
case
 A suspected or probable case should not be discarded based
on negative result from an oropharyngeal, anal, or rectal swab
or from blood test alone.
Case notification
 All suspected, probable or confirmed monkeypox
cases must be notified to the District Health Office
within 24 hours via phone call.
 This is then followed by the Borang Notifikasi
Penyakit Berjangkit under “other life-threatening
microbial infection” (Annex 4) or input patient’s
information into the e-Notification System
Case management
 A suspected and probable mpox case should be quarantined at
home while waiting for their lab result.
 Those who are not able to comply with home surveillance can
be considered for admission.
 Confirmed mpox case – an isolation order should be issued.
 Isolation precaution should be practiced until all lesions have
resolved, and a fresh layer of skin has formed.
 All confirmed case should be admitted if:
 They are in a dire situation that their health and condition need to
be monitored closely,
 They have multiple co-morbidities and the likelihood for any
complication to arise is high, and
 Non-compliance to the isolation order other than hospital facilities
can facilitate the transmission in the community.
Admission criteria
 Patients who are clinically ill OR have the following symptoms:
 Persistent fever beyond day 5
 Exertional dyspnea, Sp02 <95% (at rest or exertion)
 Dehydration
 Secondary infection of skin lesions
 Reduced level of consciousness
 Blurring of vision
 Patients with uncontrolled medical conditions,
immunocompromised status, pregnant women, extreme of age
(<2 years or >60 years old).
 Patient who do not fulfill the above criteria but are not
suitable for home surveillance, to consider admission.
Checklist for suitability of patients to
undergo home surveillance
 Has a separate bedroom with en-suite bathroom; if not
common bathroom with frequent disinfection.
 Has access to food and other necessities
 Has access to face mask, glove and disinfectant at home
 Able to seek medical care if necessary and return with
own private transport
 Able to adhere to instruction to follow home surveillance
order
 Able to stay away (at least 2 meter apart) from the high
risk household members.
Case treatment
No proven definitive
treatment for mpox virus
infection
Main principle of management are
rapid isolation to control the
outbreak and symptomatic treatment.
Antivirals like Tecovirimat, Cidofovir,
Vaccinia immune globulin intravenous
have been listed as part of treatment
considerations.
• Specific treatment should be
considered for severe disease i.e
hemorrhagic disease, large
number of lesions, sepsis,
encephalitis, ocular or periorbital
infection, others that required
admission.
• Involvement of anatomical area
which may results in sequelae
like scarring or stricture i.e lesion
on pharynx that causing
dysphagia, or need parenteral
feeding.
• High risk of severe disease i.e
immunocompromised,
paediatrics age group, pregnant
women.
• People with conditions affecting
skin integrity – atopic dermatitis,
eczema, burns
Treatment
 Skin care
 To prevent secondary bacterial infection
 To promote lesion healing
 To minimize insensible fluid loss
 Therapeutic consideration
 Avoid scratching and picking the skin lesion
 Wash/bath : use gentle cleanser or soap twice a day
 Apply calamine lotion twice a day to relieve itch and for soothing
effect
 Topical abx/antiseptic can be applied to excoriated lesions
 Avoid using topical corticosteroid onto skin lesions.
 To alert if fever, pain/tenderness, erythema, edema, exudate
Treatment
 Abscess
 Antiseptic wash with occlusive dressing, systemic abx, consider surgical
debridement
 Pain management
 Most common c/o especially if lesion at specific site i.e anus – causing
proctitis
 PCM, NSAIDs for pain control
 Topical i.e lignocaine can be given
 Gabapentin and opioids can be use for short term severe pain management
 Anogenital lesions
 Stool softener – syr lactulose
 Warm sitz bath
 Analgesia
 Oropharyngeal lesion
 Complication like tonsillar abscess, epiglottitis – considered rinsing mouth
with clean salt water or oral antiseptic mouthwash
Contact tracing
Close contact - HCW

 Health workers who have unprotected exposures

(i.e., not wearing appropriate PPE) to patients
with monkeypox or possibly contaminated
materials do not need to be excluded from
work duty if asymptomatic, but should
undergo active surveillance for symptoms,
which includes measurement of temperature at
least twice daily for 21 days following the
exposure
Infection and prevention control (IPC)
 For suspected or confirmed patients with mpox
 HCW should implement standard, contact and droplet
infection control precautions.
 Hand hygiene as per the WHO 5 moments
 Personal protective equipment (PPE)
 Disinfection and sterilization
 Environmental hygiene – cleaning and disinfection
 Waste management
 Linen management
 Patient transferring
Specimen Collection
Specimen collection, handling and transportation
Interim guideline Monkeypox WHO

HCW involved in sample collection

for MPXV virus
must wear recommended PPE
•ie. disposable gown, double
gloves, N95 (or comparable)
filtering disposable respirator , eye
protector (goggles or face shield)
•Wash hands with soap and water
before and after sample collection
Swab the lesion
Two lesions of the Lesions swabs, crusts
vigorously using
same type should and vesicular fluids
Dacronor
be collected in the should not be mixed in
polyester flocked
same tube the same tube
swabs, to ensure
adequate viral
Packaging and handling
Container
should be label
appropriately
before
specimen
collection
 Important checklist before specimen
transportation

1. Laboratory Request Form - attched at

the top of the triple packaging
2. Label the outside sample box with
‘Monkeypox’ and (UN 3373) under
IATA rules and regulations for
diagnostic specimens
3. Place specimens from a single patient
into a biohazard
bag.
4. Blood tubes should be placed in
individual Styrofoam holders.
5. All specimens should be shipped on ice
packs at 4⁰C.
6. Specimens may be stored at 4⁰C up to
48 hr before processing.
Reference

 Guideline MPOX management in Malaysia 2nd edition 18

January 2023
 Slides from Taklimat Monkeypox 5th Oct 2023