Monkeypox can ‘mask’ like other conditions, with wide range of symptom severity

As global monkeypox outbreaks made headlines, Dr. Antoine Cloutier-Blais in Montreal began seeing patients with unusual — and often painful — bodily injuries.

In early June, the family doctor and his colleagues treated about 15 patients with confirmed infections, out of about 100 laboratory-confirmed cases reported so far in Quebec. People with suspected infections soon began showing up at the clinic almost daily.

Cloutier-Blais began to notice some interesting trends.

The smallpox lesions, he found, were not looking quite like what he saw in photos circulating online of infected people in parts of Africa, where the virus has been found for decades.

“The lesions are much smaller and usually very localized,” he said, adding that there is also a “very broad spectrum of different types of presentations.”

In some cases, the lesions appear on or within various areas of the body, including the patients’ mouth, genitals, or anal region, sometimes spreading to the limbs or trunk or appearing all over the body.

But for other patients, the visible symptoms were much more subtle — even a single skin tag.

Medical experts in several countries are noticing similar patterns. In this unprecedented outbreak – which is offering many global doctors their first real-world experience with this disease – there is a clear range of severity, from classic full-body rashes that require hospital admission and pain medication, to cases where smallpox presents as a mild infection that can be easy to miss or easy to confuse with other conditions.

And while these infections are typically treatable, there is also growing concern that this virus could spread to vulnerable populations at greater risk of life-threatening illness.

Eruption could be the first warning sign

Photos taken in clinical settings show smallpox lesions on patients in the UK during a global outbreak of cases beyond the typical endemic regions of the virus in Africa. (UK Health Security Agency)

Monkeypox often appears as a flu-like illness, showing symptoms such as fever, chills, and muscle stiffness that can predate the telltale lesions.

However, for recent patients in the US, the appearance of a rash was often the first warning sign that they were ill.

“In these new cases, what we’re hearing is that those [pre-rash] symptoms can be very mild or not even noticed,” said Dr. Agam Rao, MD, US Centers for Disease Control and Prevention, Poxvirus and Rabies, during an interview with the medical journal JAMA.

For doctors unfamiliar with the virus, it can also be difficult to tell some chickenpox infections from chickenpox — or certain sexually transmitted infections like herpes and syphilis.

“Smallpox can disguise itself as other conditions,” said Dr. Rosamund Lewis, Canadian physician and World Health Organization (WHO) technical lead for the smallpox outbreak.

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Bodily injuries linked to this virus also often start in the head, before progressing to the arms and legs, but Rao said US patients have experienced rashes in the genital or perianal regions first, including some people who have suffered from inflammation of the rectum.

a case study published in the medical journal of infectious diseases Eurosurveillance analyzed the experience of an HIV-positive man in his 30s who was diagnosed with monkeypox in May after traveling and engaging in sexual activity in Europe.

The man’s initial symptoms were painless pustules on his penis, which soon got worse. The lesions became painful and itchy, so the man developed a fever three days later, with the rash spreading to his torso, face and limbs over the next few days – requiring two trips to the doctor and a brief hospital stay.

“When examined in the hospital, the penile lesions had widely formed crusts and the lesions on the hands and lower limbs were painless papular pustules,” the case study authors wrote.

‘Monkeypox can affect anyone’

Monkeypox is not known to be a sexually transmitted infection, but it can be spread through various forms of close contact with other people. This includes skin-to-skin contact, even if someone has minimal injuries to their genital regions, or through respiratory droplets if someone has an injury inside their mouth, noted the WHO’s Lewis.

While there are some reports of newly infected women around the world, the majority of infections in this global outbreak – now with around 1,000 confirmed cases and counting – have occurred among men who have sex with men, prompting awareness campaigns by and for members of the that community.

“Of course, smallpox can affect anyone, any gender, any sexual orientation,” said Dane Griffiths, director of the Gay Men’s Sexual Health Alliance in Ontario, where about a dozen cases have been reported, mostly in Toronto.

“But given the current cases we’re seeing and the outstanding questions about the dynamics of monkeypox transmission in our community, we’re making people aware of this.”

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Cloutier-Blais highlighted the importance of rapid community mobilization, including “impressive” participation in monkeypox vaccination clinics in Montreal.

Since launching in late May, more than 1,600 doses have been provided to members of the public who may be at greater risk of contracting smallpox from sexual contact or work-related reasons.

“Anyone can eventually show symptoms,” Cloutier-Blais said.

As global monkeypox outbreaks made headlines, Dr. Antoine Cloutier-Blais in Montreal began seeing patients with unusual — and often painful — bodily injuries. (Guillaume Steben/CBC News)

‘Stay isolated’ if injuries appear

When it comes to mild cases, the Montreal doctor said his patients don’t need much medical support.

“We simply suggest that individuals cover their injuries and stay isolated as much as possible, with a mask if they need to meet other people, and stay at home and cover their injuries until they are fully healed,” he explained.

More severe cases, however, required hospitalization, with patients experiencing “fever or very severe pain that is difficult to control with oral medication alone.”

So far, no one has died during this recent global outbreak outside of Africa, WHO Director-General Tedros Ghebreyesus told a news conference on Wednesday. But the disease can be deadly in some cases, particularly for high-risk groups such as pregnant women, children and people with compromised immune systems.

Tedros urged countries to make serious efforts to stop the transmission of the virus in order to prevent smallpox from spreading more widely and spreading to these vulnerable populations.

“The risk of smallpox becoming established in non-endemic countries is real,” he said.

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