It’s not the monkey pox doctors thought they had

At the start of the monkeypox outbreak, a man in his 20s arrived at the northern California emergency room with tiny blisters on his lips, hands and back. Within 12 hours, doctors diagnosed him with monkeypox.

This is where their certainty ended. The patient had no fever, body aches, weakness, pain or other symptoms typical of the disease. He didn’t know when or how he had been infected. He hadn’t had sexual contact with anyone in months, he said, and hadn’t touched – as far as he knew – anyone with smallpox, as the lesions are called, or other symptoms.

At the start of the outbreak, scientists thought they knew when and how the monkeypox virus had spread, what the disease looked like and who was most vulnerable. The 47,000 cases identified worldwide have upended many of those expectations.

Patients with monkeypox presented with what looked like mosquito bites, pimples or ingrown hairs, not the large pustules typically associated with the infection. Some didn’t even have visible lesions but felt excruciating pain when swallowing, urinating or emptying their bowels.

Some had headaches or depression, confusion and seizures. Others had serious eye infections or inflammation of the heart muscle. At least three of the six deaths reported so far have been linked to encephalitis, an inflammation of the brain.

“We really see a very, very wide range of presentations,” said Dr. Boghuma Titanji, an infectious disease physician at an Atlanta clinic that serves people living with HIV.

Scientists now know that the monkeypox virus hides in saliva, semen and other bodily fluids, sometimes for weeks after recovery. The virus has always been known to spread through close contact, but many researchers suspect the infection can also be transmitted through sex itself.

The California patient had the virus in the throat, but no respiratory symptoms, and in the rectum, but without pain or smallpox. The case underscores other research suggesting the virus can be spread even by people with atypical or asymptomatic infections, said Dr Abraar Karan, who diagnosed the patient and published a recent case report.

In another study, also published this month, anal swabs from 200 men with no symptoms found 13 positive for monkeypox. Only two of them subsequently developed symptoms.

“It is no longer correct to say that it cannot be transmitted asymptomatically,” said Dr Chloe Orkin, an infectious disease physician at Queen Mary University of London. “I think that means our working model of how it spreads is incorrect.”

At the start of the outbreak, the Centers for Disease Control and Prevention said “people without symptoms of monkeypox cannot transmit the virus to others.” On July 29, the agency changed that wording to say that “scientists are still investigating” the possibility of asymptomatic transmission.

In a statement to The New York Times, an agency spokesperson acknowledged recent evidence that asymptomatic cases were possible, but said it was still uncertain whether people without symptoms could spread the virus and that further research was needed.

When the first dozen cases of monkeypox appeared in Europe, the spread of the virus through sexual contact and genital lesions surprised many scientists. But it shouldn’t have.

Nigerian researchers reported a similar trend in 2017, when they documented 228 cases, many of them young men with genital ulcers. (Patients identified as heterosexual in a later study, but Nigeria criminalizes homosexual behavior.)

The cases were the first reported in Nigeria in 40 years, and the World Health Organization has helped the country “mount the local response, with the aim of controlling the spread”, said Fadela Chaib, spokesperson for WHO.

But the patients’ unusual symptoms went unnoticed. “If what’s happening in Europe and the Global North hadn’t happened, I don’t think this document would have been discussed,” said Dr Dimie Ogoina, who led a study describing the cases.

“We have this disease that is over 50 years old, and there’s a lot we still don’t know – and that’s because the disease has been largely confined to Africa,” he said. .

At the end of May, Orkin contacted several international colleagues to set up what turned out to be the largest monkeypox study. Hundreds of doctors from 16 countries eventually provided information about the cases they were seeing.

They changed the reporting forms as the disease became clearer, adding the possibility of a single smallpox, throat or rectal damage and medical complications – features that “were not included in international monkeypox case definitions,” Orkin said.

The resulting analysis of 528 patients was published in the New England Journal of Medicine on July 21. Days later, Orkin alerted several national health agencies, knowing the results are expected to change the case definitions doctors look to when diagnosing patients.

The UK Health Security Agency and the European Centers for Disease Control both responded on the same day. Britain added some of the new symptoms to its monkeypox case definition three days later. The European agency invited Orkin to present its findings.

In an interview in late July, Orkin explained that during pandemics, public health agencies are considered experts and officials educate doctors about the disease and its treatment. Yet it is clinicians who see the symptoms firsthand.

“It seems to me that consulting with clinicians in the field might have been helpful,” she said. National health agencies have been slow to understand the many manifestations of the virus in the current outbreak, she added.

Orkin is president of the Medical Women’s Federation, former president of the British HIV Association and a board member of the International AIDS Society. “I have a loud voice,” she says, “and I always have trouble getting a response.”

Senior WHO officials responded to Orkin on August 2, asking to discuss the cases she and her colleagues had described. The CDC did not respond to Orkin but added rectal pain and bleeding, along with other new symptoms, to its advice to clinicians on August 5.

The new CDC definition mentions lesions in the mouth but does not describe the range or extent of smallpox in the mouth, eyes, and urethra. In its statement, the agency said it was aware of Orkin’s findings and had begun studies “that will help us better understand the range and extent of lesions at these and other body sites.”

Based on reports that the virus lingers in semen for weeks, Britain has recommended that men recovering from monkeypox use condoms for 12 weeks after infection, a tacit acknowledgment that this may be a route of transmission.

The CDC did not follow up, saying “researchers are working with our partners to find out if, and how often, the virus is spread through contact with semen.”

The agency should advise men to wear condoms for a few weeks, as Britain has done, Karan said. “We don’t know how long people can transmit through semen,” he said. “I think they should communicate that clearly.”

For patients, outdated case definitions and advice can have serious consequences. Cameron French, 30, was exposed to the virus on July 6. Two weeks later, he developed a sore throat, head and body pain, painful urination and three bumps – on his face, a thigh and an elbow.

However, during his first visit to a clinic on July 25, his doctor did not make the connection between the symptoms. She told him the bump on his thigh was an ingrown hair and tested him for a urinary tract infection.

He returned there three days later. This time the doctor agreed to test him for monkeypox. After testing positive, he had to push again, this time for the antiviral drug tecovirimat.

French said he was very frustrated with the lack of guidance on how to distinguish potential new smallpox from a pimple so he could end his month-long isolation. “It’s been a big, ambiguous question mark,” he said. “It was difficult.”

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