A small number of cases of monkeypox have been confirmed in London in the past few weeks. It is important clinicians are aware of how the illness presents and current case definitions so that we can manage patients appropriately if they present to primary care.
If a clinician suspects monkeypox, they need to speak to their local infectious disease team and health protection team; this is an evolving situation being managed nationally and guidance may change in the coming weeks.
The UK Health Security Agency (UKHSA) has produced a helpful case management algorithm, available in the Useful Links section below.
Monkeypox is a rare disease that is caused by infection with monkeypox virus. Monkeypox does not spread easily between people.
The virus enters the body through broken skin (even if not visible), the respiratory tract, or the mucous membranes (eyes, nose, or mouth).
Person-to-person spread is very uncommon, but may occur through:
- contact with clothing or linens (such as bedding or towels) used by an infected person
- direct contact with monkeypox skin lesions or scabs
- coughing or sneezing of an individual with a monkeypox rash
Thankfully, for most, monkeypox is a self-limiting illness from which people recover over a few weeks. Severe illness is more likely in immunocompromised patients. It presents with a prodrome of fever, headache, myalgia, arthralgia, lymphadenopathy, and fatigue.
Within one to five days of this, the patients develop a rash typically starting in the mouth and on the face and spreading over the body, including the palms and soles of the feet. The rash starts as a vesicle then becomes a pustule, which umbilicates and then crusts over to form a scab.
The UKHSA has shared the following case definitions to consider when speaking to patients.
- a person with a febrile prodrome† compatible with monkeypox infection where there is known prior contact with a confirmed case in the 21 days before symptom onset
- a person with an illness where the clinician has a high suspicion of monkeypox (for example, this may include prodrome or atypical presentations with exposure histories deemed high risk by the clinician, or classical rash without risk factors)
† Febrile prodrome consists of fever ≥ 38°C, chills, headache, exhaustion, muscle aches (myalgia), joint pain (arthralgia), backache, and swollen lymph nodes (lymphadenopathy).
A person with a monkeypox compatible vesicular-pustular rash plus at least one of the following epidemiological criteria:
- exposure to a confirmed or probable case in the 21 days before symptom onset
- history of travel to an area where monkeypox is endemic, or where there is a current outbreak in the 21 days before symptom onset (currently West and Central Africa, Spain, Portugal and US)
- gay, bisexual and other men who have sex with men (GBMSM)
Current National IPC guidance advises fit tested FFP3 mask, eye protection, gown, and gloves for assessment of patients with suspected monkeypox. In primary care, potential cases could initially be assessed remotely via telephone and using digital images or video consultation.
If it is felt that a patient fits the case definition, they should be discussed with your local infectious diseases team and health protection team who can arrange testing and appropriate contact testing.