Emergencies: Monkeypox doesn’t follow the rules : Emergency Medical News

So we are facing a second epidemic, monkeypox.

I would like to add in brackets that as I write this, the US Centers for Disease Control and Prevention, so to speak, has just released a case report on the first case of paralytic poliovirus in a decade.

I’ll also add this in brackets, but last week the World Health Organization called for help to rename monkeypox, and the frontrunner I heard was OPOXID-22 (Orthopoxvirus disease 2022). and MPXV (monkeypox virus).

I practice in San Francisco, which has been relatively immune to COVID cases and deaths, but has been hit hard by monkeypox. It has the highest number of monkeypox cases per capita of any major city. (For example, Los Angeles has about 150 more patients than San Francisco, but about 9 million more patients.)

Why You Get Monkeypox

Monkeypox is an orthopoxvirus first identified in Copenhagen in 1958 (which is why I think it should be called a den).mark, but that’s another story). It’s been confirmed in some monkeys in the lab there, but monkeys are probably not reservoirs for this virus. It’s probably some adorable African squirrels. (Do an image search for “sun squirrel” or “rope squirrel” and deny the cuteness, dare I say). So maybe more realistically squirrelpox. anyway.

Monkeypox is endemic in parts of Africa, but Nigerian doctors and the Nigerian Center for Disease Control issued warnings in 2017 over concerns about human-to-human transmission, especially sexual transmission. One: there were a lot of warnings. Second, the US scrapped her 20 million doses of her JYNNEOS vaccine, which is now in high demand. This was probably given or sold to Nigeria and, as you know, was to help with the local monkeypox epidemic.

Fast-forward to May of this year, and we began to see numerous new cases of monkeypox, especially among men who had sex with men, especially among men who had multiple new sexual partners. It has thrown in a number of federal-level missteps with multiple three-letter US agencies, with cases doubling every 10-12 days since the beginning of July.

Almost all cases are now found in men who have sex with men (90-95% or more). We believe that the greatest means of transmission is skin-to-skin contact, for example in people having sex (more skin than clothing).

The Lesions We See Now (Did you know that monkeypox broke out in the Midwest in 2003?) tendency Although located in areas of the body frequently involved in sexual activity, such as the genitals, anus and rectum, and mouth, lesions can honestly be anywhere.

We will also see cases doubling every two weeks, with at least one case of monkeypox. Especially if you live near an urban area (which also tends to be gay men).

classically may not exist

Let’s talk a little more about these lesions. Even the “classic” look can vary from person to person and course of disease.

• They may begin as slight macular redness.
• Then they can be maculopapular.
• Most likely, at some point it turns into a typical “pox”, reminiscent of chickenpox, smallpox, etc.
• They may also develop an umbilical cord (the point at the top of the lesion).
• Many later ulcerate and lose their roofs.
• Eventually (after 1-3 weeks) they should do it scab.
• And the scab will fall off.
• The patient is then considered cured/cured/non-infectious.

You’ll notice I used “may” and “should” a lot in that list. That’s because the disease isn’t always what it should be. Textbooks present rather different descriptions of monkeypox in several different ways.

• Location: Previous monkeypox infections tended to involve the face and rarely the genitals. This time a large proportion is seen in the genitals.
• Quantity: Approximately 10% of patients may have only one solitary lesion. Most are 2 to 10, some are over 50.
• Mucous membranes: More patients have mucosal lesions in the mouth or rectum compared to previous outbreaks. Approximately 5% of patients in one case series had only mucosal lesions and no cutaneous lesions.
• Timing: Previous monkeypox infections tended to have lesions all appearing at once and all at the same age.
• Prodrome: Classically, patients are all assumption Before skin lesions form, there is a uniform aura of fever, headache, fatigue, and lymphadenopathy. , which may behave like a classic “prodrome”.

And (of course there are others) we see several other presentations where monkeypox is not presented in the way it is supposed to be “supposed” as described in some case series. .

• Peritonsillar abscess, tonsillitis, and tonsillar effusion. It may be accompanied by fullness or asymmetry of the tonsils.
• Skin Abscess: This looks like a regular old subcutaneous skin abscess that you are willing to cut open and drain and drain home.
• Severe rectal pain: These patients presented with isolated rectal pain and proctitis. Anoscopy reveals multiple lesions that are monkeypox.
• Maculopapular rash: This looks like a nonspecific or viral rash. Turned out to be monkeypox.

I would say that all the patients I saw had very classic lesions.

I think these lesions need to be investigated more. Obviously, classic lesions should be swabbed to confirm the diagnosis, but if they look atypical, perhaps no risk factors or exposures, or “this could be monkeypox” or “Could this be monkeypox?”

Reasons you don’t want to miss

This is a very reasonable concern for emergency physicians, especially since our main focus is not to miss life-threatening diagnoses. But when a patient comes back with shortness of breath, is hospitalized with hypoxia, and is diagnosed with sarcoidosis, it’s probably a little disappointing, right?

None of us want to do the wrong thing, miss something, get back on our feet, or give the wrong advice. Sure, calling the patient back in 24 hours probably won’t do him much harm. Ankle of the day. Same as monkeypox: suboptimal for several reasons:

• Patients may recover with pain management problems, impose their diagnosis on colleagues, or fail to make a proper diagnosis, putting other members of the team and community at risk.

And these lesions can be very painful. We offer multiple different modalities of pain relief including opioids, acetaminophen, NSAIDs, topical lidocaine, gabapentin, and even mesalamine suppositories for patients with severe rectal pain and lesions.

• These patients are in complete isolation and do not want to pass the disease on to others. There probably isn’t a same-day PCR test that will tell you if you have monkeypox in the ED, but at least you can express your professional concern by saying you’re pretty sure you have monkeypox. Most patients (especially gay men) are probably in the ED because they are very suspicious or worried that they have monkeypox. But if you say it looks like streptococcus, they probably won’t take it too seriously.
• You don’t want to cut into a monkeypox wound or spray monkeypox pus nearby or in the air.
• A treatment called Tecovirimat (TPOXX) appears to speed up healing of lesions (and thus, arguably, shortens the duration of infection in patients). From the CDC’s Strategic National Stockpile, he often understands the lengthy and cumbersome process required to obtain TPOXX, so he can refer these patients to local infectious disease and HIV doctors or county public health teams. Tying is probably worth it. (Hopefully, by the time this article goes to print, it will be more widely available.)

Many of us are working hard to have access to more vaccines, easier access to TPOXX, better and faster testing options, and better education to stop this disease. increase. I hope cases are down, vaccines are plentiful, TPOXX is easily available, and testing is happening quickly by the time you read this. But one of the reasons I am writing this is because I need an alternative to simple hope and prayer.

Dr. WalkerI’m an emergency doctor at Kaiser San Francisco. He is the developer and co-author of his MDCalc. (www.mdcalc.com), Medical calculator for clinical scores, equations, and risk stratification.There is also an app (http://apps.mdcalc.com/), and NNTs (www.thennt.com), A number of therapeutic tools to communicate benefits and harms. follow him on twitter@ Graham Walker, Read his past column at.