This is not the monkeypox the doctors thought they knew

Early in the monkeypox outbreak, a man in his 20s presented to the emergency department in Northern California with tiny blisters on his lips, hands, and back. Within 12 hours, doctors diagnosed him with monkeypox.

That’s where their certainty ended. The patient had no fever, aches, weakness, pain, or other symptoms typical of the disease. He did not know when or how he was infected. He hasn’t had sex with anyone in months, he said, and hasn’t touched – as far as he knows – anyone with chickenpox, as the wounds are called, or other symptoms. .

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

Patients with monkeypox emerge with what looks like mosquito bites, boils, or ingrown hairs, not the large pustules typically associated with infection. Some don’t even have visible but felt damage pain when swallowurinate or defecate.

Some experience headaches or depression, confusion, and seizures. Others have severe eye infections or myocarditis. At least three of the six deaths reported to date have been linked to encephalitis, an inflammation of the brain.

“We’re really seeing a very, very broad presentation,” said Dr. Boghuma Titanji, an infectious disease physician at an Atlanta clinic that serves people living with HIV.

Scientists now know that monkeypox virus lurks in saliva, sperm and other body fluidssometime for a few weeks after recovery. Viruses have always been known to spread through Close contactbut many researchers suspect that the infection can also be sexually transmitted.

The California patient had the virus in his throat, but no respiratory symptoms, and in his rectum, but no pain or chickenpox. This case highlights another study showing that the virus can spread even among people with atypical or asymptomatic infections, said Dr. Abraar Karan, who diagnosed the patient and published it. a recent case report.

In another study, also published This month, rectal swabs from 200 asymptomatic men showed 13 positive for monkeypox. Only two of them later developed symptoms.

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

Early in the outbreak, the CDC said that “people without monkeypox symptoms cannot transmit the virus to others.” Organ changed the way it was said on July 29 to say that “scientists are still studying” the possibility of asymptomatic transmission.

In a statement to The New York Times, a spokesman for the agency acknowledged recent evidence that asymptomatic cases were possible but said it remained uncertain whether people without symptoms can spread the virus and requires further study.

When the first several 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 be.

Nigerian researchers reported a similar pattern in 2017, when they recorded 228 casesmany of them young man with genital ulcers. (Patients identified as heterosexual in one the next researchbut Nigeria criminalizes homosexual behavior.)

Fadela Chaib, a spokeswoman for the organization, said these cases were reported in Nigeria for the first time in 40 years, and that the World Health Organization had helped the country “intensify the local response, with the aim of helping to strengthen the local response.” to control the spread”.

But the patient’s unusual symptoms went unnoticed. Dr Dimie Ogoina, who led a study that described the cases, said: “If what is happening in Europe and the Global North doesn’t happen, I don’t think that article would be discussed.

“We’ve had this disease for more than 50 years, and there’s a lot we still don’t know – and that’s because the disease is largely confined to Africa,” he said.

At the end of May, Dr. Orkin contacted several international colleagues to put together the largest study of monkeypox. Hundreds of doctors from 16 countries ended up contributing information about the cases they were seeing.

They changed reporting forms as the disease became more concentrated, adding the possibility of a nodule, a lesion in the throat or rectum, and medical complications – features “not in international case definition of monkeypox,” said Dr. Orkin.

Results of analysis of 528 patients published, published in the New England Journal of Medicine on July 21. A few days later, Dr. Orkin alerted several national health authorities, knowing the findings would change the case definitions doctors use. reference when diagnosing a patient.

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

In an interview in late July, Dr Orkin reflected that in times of pandemic, public health authorities are seen as experts, and officials educate doctors about the disease and how treat it. However, it is the clinicians who witness the symptoms first-hand.

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

Dr Orkin is president of the Federation of Medical Women, formerly president of the British HIV Association and a board member of the International AIDS Society. “I have a loud voice,” she said, “and I still find it difficult to get a response.”

Senior WHO members responded to Dr Orkin on August 2, asking to discuss the cases she and her colleagues described. The CDC did not respond to Dr. Orkin but added rectal pain and bleeding, among other new symptoms, to Guidelines for clinicians on August 5.

The new CDC definition addresses oral lesions but does not describe the extent or importance of chickenpox in the mouth, eyes, and urethra. In its statement, the agency said it was aware of Dr Orkin’s findings and had begun studies “that will help us better understand the scope and significance of the lesions at these sites”. this and other locations on the body.”

Based on reports that the virus persists in semen for weeks, the UK recommends that men recovering from monkeypox use a lot of condoms for 12 weeks after infection, a tacit recognition that this could be a route of transmission.

CDC has Not with that, saying that “researchers are working with our partners to find out if and how often the virus is spread by contact with semen.”

Dr Karan said the agency should advise men to wear condoms for several weeks, as the UK has done. “We don’t know how long people can transmit semen,” he said. “I think they should announce that clearly.”

For patients, outdated case definitions and guidelines can have serious implications. Cameron French, 30, was exposed to the virus on July 6. Two weeks later, he developed a sore throat, headaches and body aches, painful urination and three bumps – on his face, thighs and elbows.

However, on his first visit to the clinic, on July 25, his doctor failed to connect the symptoms. She told him the bump on his thigh was an ingrown hair and tested him for a urinary tract infection.

Three days later he returned. This time, the doctor agreed to test him for monkeypox. After testing positive, he had to push again, this time to get the antiviral tecovirimate.

Mr. Phap said he was most frustrated by the lack of guidance on how to distinguish a potential new pox that could end the month-long isolation. “It’s a big, unclear question mark,” he said. “It’s really hard.”

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