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Recognizing Mpox

Read more about Mpox transmission at the CDC

Progression of Mpox
Images courtesy of (Titanji et al 2022, Open Forum Infect Dis [5]).

Stage Duratio Characteristi Lighter Pigment Darker Pigment

n cs
Macul 1-2 Macular
e Days lesions
appear,
typically 2-
5mm in
diameter

Papule 1-2 Lesions

Days progress
from
macular
(flat) to
papular
(raised)

Vesicl 1-2 Lesions

e Days become
vesicular
(raised and
filled with
clear fluid)
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Pustul 5-7 Lesions

e Days become
pustular
(filled with
opaque
fluid) –
raised,
round, and
firm to
touch

Scabs 7-14 By the end

Days of 2 weeks,
pustules will
have crusted
and scabbed
over, then
begin falling
off

Identifying mpox can be tricky. The lesions evolve through multiple stages and can resemble other
rashes at these different stages, including:
• Primary or secondary syphilis
• Acne
• Blisters
• Herpes
• Varicella-zoster
• Molluscum

Lesions may be single, often at the site of initial exposure, while others may have multiple lesions.
Lesions usually appear simultaneously and go through the same stages simultaneously in a particular
location on the body, but they may later appear elsewhere and developmental stage may lag behind
the initial lesions
The most clearly mpox lesions are pustules which will develop umbilication (central dimpling) though
initially lesions are not umbilicated. These pustules, if squeezed, do not have fluid or pus, and are
rubbery in texture.
Diagnosis can be made with other symptoms. Patients may have rectal pain or bloody stools or purulent
discharge. They may have a sore throat, swollen lymph nodes, fever or other prodrome symptoms.
The incubation period is 3-17 days and patients may feel fine then or may have a prodrome right before
symptoms. The lesions once they appear will take 2-4 weeks normally to go through the stages before
scabbing and desquamating.
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Progression of mpox in pictures

Mpox after occupational exposure over the course of 15 days

(Images courtesy of Thornhill et al 2022, Lancet [6])

Various mpox presentations

(Image courtesy of CDC via UK Health Security Agency [8])

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Progression of mpox after scarring

Development of solitary lesion on right upper inner thigh, tracking laterally to outer thigh.

(Images courtesy of Patel et al 2022 BMJ [9])

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Range of locations of mpox lesions

(Image courtesy of Tarín-Vicente et al 2022, Lancet [10])

Pustules can also appear in the genital and pubic region, perianal skin, and penile glans and foreskin, but
are not pictured here.

Mpox lesions on mucosal surfaces

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Lesions may be on mucosal surfaces and may be harder to identify.

(Images courtesy of Thornhill et al 2022, NEJM [7]

Differential Diagnosis
Varicella – The most likely diagnostic consideration in a patient with a vesicular rash is varicella.
Unlike varicella lesions, which are vesicular fluid filled lesions, mpox lesions are typically pseudo-
pustules, which resemble pustules but do not contain fluid or pus. Varicella lesions are usually in
different stages of development and healing, whereas mpox lesions traditionally are in the same
stage, but mpox lesions can develop in crops at a different stages in different locations.

(Image courtesy of CDC)

Herpes simplex virus – Herpes simplex virus (HSV) can present with both oral and genital lesions similar
to mpox.
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(Image courtesy of Fatahzadeh et al 2007, J Am Acad Dermatol. [11])

Other sexually transmitted infections – For those who present with penile, vaginal, or perianal
ulcerated lesions, primary or secondary syphilis, lymphogranuloma venereum, or Haemophilus ducreyi
should be considered in the differential diagnosis. In patients with inflammation of the rectum,
lymphogranuloma venereum, chlamydia, gonorrhea, and syphilis should be considered. Throat
features of mpox may be mistaken for bacterial tonsillitis or gonorrhea or syphilis.

Molluscum contagiosum – Similar to mpox, molloscum it is caused by a poxvirus and 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.

(Courtesy of Chen et al 2013, Lancet Infect Dis. [12])

Smallpox – Although the virus has been eradicated, given storage of samples, the risk of bioterrorism
has been considered.
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References

1. Nolen LD, Osadebe L, Katomba J, et al. Extended Human-to-Human Transmission during a

Monkeypox Outbreak in the Democratic Republic of the Congo. Emerg Infect Dis. 2016 Jun;22(6):1014-21.
doi: 10.3201/eid2206.150579. Erratum in: Emerg Infect Dis. 2016 Oct;22(10 ): PMID: 27191380; PMCID:
PMC4880088.

2. Brown K, Leggat PA. Human Monkeypox: Current State of Knowledge and Implications for the
Future. Trop Med Infect Dis. 2016;1(1):8.Published 2016 Dec 20. doi:10.3390/tropicalmed1010008

3. Minhaj FS, Ogale YP, Whitehill F, et al. Monkeypox Response Team 2022. Monkeypox Outbreak -
Nine States, May 2022. MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):764-769. doi:
10.15585/mmwr.mm7123e1. PMID: 35679181; PMCID: PMC9181052.

4. Petersen E, Kantele A, Koopmans M, et al. Human Monkeypox: Epidemiologic and Clinical

Characteristics, Diagnosis, and Prevention. Infect Dis Clin North Am. 2019 Dec;33(4):1027-1043. doi:
10.1016/j.idc.2019.03.001. Epub 2019 Apr 11. PMID: 30981594; PMCID: PMC9533922.

5. Titanji BK, Tegomoh B, Nematollahi S, et al. Monkeypox: A Contemporary Review for Healthcare
Professionals. Open Forum Infect Dis. 2022 Jun 23;9(7):ofac310. doi: 10.1093/ofid/ofac310. PMID:
35891689; PMCID: PMC9307103.

6. Thornhill JP, Palich R, Ghosn J, et al. Share-Net writing group. Human monkeypox virus infection
in women and non-binary individuals during the 2022 outbreaks: a global case series. Lancet. 2022 Dec
3;400(10367):1953-1965. doi: 10.1016/S0140-6736(22)02187-0. Epub 2022 Nov 17. PMID: 36403584;
PMCID: PMC9671743.

7. 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 Aug 25;387(8):679-691. doi:
10.1056/NEJMoa2207323. Epub 2022 Jul 21. PMID: 35866746.

8. Centers for Disease Control and Prevention. (2022, August 23). Clinical recognition/Mpox.
Centers for Disease Control and Prevention. Retrieved December 26, 2022, from
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html

9. Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox
in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul
28;378:e072410. doi: 10.1136/bmj-2022-072410. PMID: 35902115; PMCID: PMC9331915.
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10. 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 Aug 27;400(10353):661-669. doi: 10.1016/S0140-6736(22)01436-2. Epub 2022 Aug 8. Erratum in:
Lancet. 2022 Dec 10;400(10368):2048. PMID: 35952705; PMCID: PMC9533900.

11. Fatahzadeh M, Schwartz RA. Human herpes simplex virus infections: epidemiology, pathogenesis,
symptomatology, diagnosis, and management. J Am Acad Dermatol. 2007 Nov;57(5):737-63; quiz 764-6.
doi: 10.1016/j.jaad.2007.06.027. PMID: 17939933.
12. Chen X, Anstey AV, Bugert JJ. Molluscum contagiosum virus infection. Lancet Infect Dis. 2013
Oct;13(10):877-88. doi: 10.1016/S1473-3099(13)70109-9. Epub 2013 Aug 21. PMID: 23972567.