How do you know if it’s Mpox?

Diagnosis requires confirmatory testing, almost always by a PCR of a swab swiped across the top of the
lesion. The question then is: how do you know which lesions to suspect in order to isolate and test the
patient?

Recognizing mpox requires clinical history and knowledge of the epidemiology, but it also requires a bit
of visual pattern recognition. It’s important to consider mpox if a lesion could be consistent with mpox, as
this will help patient care and pain control while also decreasing further transmission.

Mpox lesions often present at the site of exposure. Lesions present in different stages, each of which can
resemble other diseases.

Here in this image from Titanji et al 2022, you can see the standard development of such lesions.

Symptoms may precede the rash, such as having a sore throat or swollen lymph node(s). Macules may be
2-5mm in diameter, followed by a papular raised lesion. Vesicles then form which are firm and do not leak
fluid. Pustules develop and then umbilicate until they form a flat ulcer or scab, until the skin heals over
and may scar.
There can be other forms of the rash; some may be associated with a diffuse erythema around the lesion
or in the absence of lesions initially and others with red streaking (lymphangitis). Sometimes, a patient can
present with multiple morphologies of these different stages at the same time.

Progression of mpox
Here are photos over 15 days from Thornhill et al 2022 of the progression of a single thumb base lesion
after a known inoculation injury in a healthcare worker.

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Here are two other progression photos from one healthcare worker with exposure to the finger and the
base of the thumb. Thornhill et al 2022

Here are some of the various presentations of mpox lesions (UK Gov)

Approved For Period: 3/13/2024 - 7/20/2024

Lesions can appear in clusters. Such clusters will normally all be at the same stage of development
(unlike varicella), but new clusters may begin with fresh early lesions and lag behind earlier clusters.
Lesions can be mucosal and painful but
not immediately visually recognized.
Thornhill et al 2022

There can be many other skin findings that may be mistaken for mpox. These may require PCR testing to
determine if they are mpox.

Some of the diseases that can look like mpox include:

Varicella – Mpox lesions do not contain fluid or pus, unlike varicella vesicular fluid filled lesions, which
may leak as they scab. Varicella lesions are usually in different stages of development and healing,
whereas mpox lesions are standardly, but not always, in the same stage. NHS

Shingles (Zoster) – Reactivation of varicella can also create lesions that

may be initially mistaken for mpox. The clustering of these vesicles in a
dermatomal distribution differentiates itself from mpox. They also do not
progress into pustules. NHS

Approved For Period: 3/13/2024 - 7/20/2024

Molluscum contagiosum – Similar to mpox, molloscum it is caused by a poxvirus. It is transmitted
through direct skin contact or fomites. This infection most commonly presents as single or multiple small,
skin-colored papules with central umbilication. It is most common in children. Immunocompromised
individuals have an increased risk for larger lesions and more widespread disease. Chen et al 2013

Herpes simplex virus – Herpes

simplex virus (HSV) can present with
both oral and genital lesions, as can
mpox. The public is usually familiar
with the appearance and the
recurrence of herpes lesions, but
new lesions, those in the
immunocompromised, on less
common body parts (say the finger),
or that are superinfected may
appear different and be harder to
distinguish from mpox clinically.
NHS

Other STDs can resemble mpox at different stages and have similar exposures. Some may occur at the
same time and be similarly painful.

Disseminated Gonococcal Infection (DGI) (in photo on

right) can cause multiple diffuse painless macules or papules
(photo near right), or petechiae that become small pustules
with central necrosis surrounded by erythema (photo far
right).

Chancroid can lead to a genital papule evolving into pustule, then a painful
ulcer (photo left) about 1–2 cm in diameter with
exudate, confused with mpox.

Lymphogranuloma venereum (LGV) (photo right) can involve a genital ulcer that
heals then later causing large painful lymph nodes; may have rectal mass

Acute HIV can be associated with diffuse, 5–10 mm macules and occasionally papules.

Approved For Period: 3/13/2024 - 7/20/2024

Syphilis – Syphilis is long known as
the “Great
Imitator” for a
reason. It can
cause a single,
painless and firm
ulcer (chancre),
often genital, but
here is a photo
showing syphilis
on the nose. The
primary lesion may however be
painful for some and be mucosal like mpox. It may also be overlooked, heal on its own, and then weeks
later secondary syphilis, develops which can result in a diffuse rash with macules turning into papules. This
secondary rash will not usually develop into the raised pustules of mpox but early in the course both can
be macules or papules, necessitating testing for mpox if unsure.

The secondary rash is more diffuse than mpox and usually symmetric
and on trunk and can be on the palms bilaterally. The rash may be
subtle or atypical. Less commonly, syphilis can be nodular and appear
more like mpox, like the image to the right.

There can also be mucosal lesions like in mpox that are harder to see,
though mpox is more often painful. Condylomata lata, flat growths
appearing wart like, can also appear.

Unexpected mimics

We have over 160 diagnoses that can be mistaken for mpox that we used to train the AI model. Many are
uncommon but then again, clinicians will be less comfortable diagnosing less common findings. Here, the
hand to the right, shows a case of orf, a viral infection which can affect those handling some livestock.

There are many other mimics. Some which may depend on

epidemiologic risk. Tick-borne rickettsia and related infections,
which vary by geography can also be mimics. Below is scrub
typhus:

Approved For Period: 3/13/2024 - 7/20/2024