Clinician Alert: CDC Update Highlights Monkeypox Case Finding and Awareness of Non-Classical Presentations

June 15, 2022

Requested actions

• Be aware that monkeypox can mimic other rash illnesses with a similar appearance (e.g., varicella, herpes, syphilis) and can present—albeit more rarely—along with other rash illnesses.
• Be aware that many monkeypox cases have presented with non-classical features (e.g., ano-genital only, asynchronous stages of lesions, multifocal rather than diffuse, absence of febrile prodrome).
• Be aware of the epidemiologic risk factors for monkeypox (see below).
• Remember to include oral, anogenital, and superficial lymph node examination when evaluating patients for monkeypox.  
• Consider testing for monkeypox and other elements in the differential diagnosis among patients with a clinically compatible rash illness, especially if the person has epidemiologic risk factors.
• Wear goggles, gown, gloves and an N-95 respirator when evaluating suspected cases.   
• Report suspected cases and coordinate specimen collection and submission with the Health District by calling 425-339-3503. Note that submission of these specimens requires approval from public health and category B handling and shipping (recently downgraded from category A). 

Background

• While only a single monkeypox case has been reported in Washington State and does not appear to have led to secondary transmission, more than 1,600 cases have been reported in more than 30 non-endemic countries worldwide.  
• In the United States, evidence of person-to-person disease transmission in multiple states and reports of clinical cases with some uncharacteristic features have raised concern that some cases are not being recognized and tested.
• The CDC update revisits case finding guidance in the light of these observations.  Open this hyperlink for the full update.
• The goal of interrupting human transmission and preventing establishment of an animal reservoir in previously non-endemic settings remains a public health priority.

Epidemiologic risk factors: within 21 days of illness onset…

• reports having contact with a person or persons with a similar appearing rash or with a person who has received a diagnosis of confirmed or probable monkeypox; OR
• had close or intimate in-person contact with persons in a social network experiencing monkeypox infections. This includes MSM who meet partners through an online website, digital application (“app”), or social event (e.g., a bar or party); OR
• traveled, within 21 days of illness onset outside the United States to a country with confirmed cases of monkeypox or where monkeypox virus is endemic; OR
• had contact with a dead or live wild animal or exotic pet that is an African endemic species, or used a product derived from such animals (e.g., game meat, creams, lotions, powders, etc.)

Additional Resources

• 2022 US Monkeypox Cases. CDC (accessed June 14, 2022). 
• Monkeypox.  Washington State Department of Health (accessed June 14, 2022).
• Epidemiologic Update: Monkeypox Multi-Country Outbreak (June 8, 2022).  European Centre for Disease Prevention and Control (accessed June 14, 2022).
• Monkeypox in Europe and North America. Snohomish Health District, May 23, 2022.  
• What Clinicians Need to Know About Monkeypox (archived webinar and slides). Centers for Disease Control and Prevention (accessed June 2, 2022).