A man arrived at an urgent care clinic in New York with red bumps on his skin in an area where he had a lot of hair.
The clinic’s doctor diagnosed the bumps as folliculitis, an infection of the hair follicles. The doctor prescribed antibiotics and sent the man, who is in his 30s, home. There he continued to help his wife with their five children, one of whom was a newborn.
Despite antibiotics, the bumps have spread beyond the first groin injuries to the palms, arms, legs, and face.
About four days after his initial doctor visit, he had a fever and returned to the urgent care clinic for a second visit. The clinic’s doctor consulted Daniel Griffin, an infectious disease specialist at Columbia University Medical Center, who advised testing for monkeypox.
A few days later, that test came back positive.
“It didn’t seem to raise any alarms, and I think part of that was that this is a happily married man who works in an office. He had no reported risk factors that would raise anyone’s concern, which is unfortunate,” said Griffin, who is now treating the man and got permission to share his story. The man declined to be interviewed.
The US Centers for Disease Control and Prevention (CDC) states that 99% of smallpox transmission is among men who have sex with men, and there is no doubt that this remains a heavily affected community.
However, infectious disease experts think the focus on this population may be leading doctors to disregard the signs of smallpox from monkeys in other population groups.
Monkeypox is not a sexually transmitted infection (STI), but it can be spread through the kind of close contact that happens in sexual and other intimate situations.
In the United States and other countries, cases have exploded among sexually active gay and bisexual men.
In a press conference on Friday, public health officials emphasized that few cases were diagnosed in people outside the men who have sex with men community, and even these external cases were related or adjacent.
The first two children in the United States who were recently diagnosed with monkeypox, for example, are believed to have contracted their infections through domestic spread.
Separately, at a Saturday meeting to educate doctors about smallpox, researcher John Brooks, medical director of the CDC’s smallpox response, said there was one case of the disease in a pregnant woman in the United States. Monkeypox can cross the placenta during pregnancy and infect babies in the womb.
Brooks said the woman gave birth to her baby and the child does not appear to have been infected. The baby was given protective antibodies called immunoglobulin as a precaution, and both mother and baby are now doing well, he said.
But this does not represent the majority of cases.
“In fact, 99% of our cases report male-to-male sexual contact,” said Jennifer McQuiston, deputy director of the CDC’s Division of Pathogens and High Consequence Pathology.
More than 3,500 cases of monkeypox have been diagnosed in the US. CDC experts said they don’t have detailed demographic information on all of these cases.
“There is no evidence to date that we are seeing this virus spread outside these populations to any degree,” added Jennifer.
‘Our network is not wide enough’
But Daniel Griffin says the situation resembles the early days of Covid-19, when it was difficult to get a test done unless you could show that you had recently traveled to Wuhan, China.
Monkeypox tests are available, and gay and bisexual men are being considered fit for testing, but many doctors are still not aware of the risk for people outside this population, Griffin said. And that’s despite outreach, webinars, and health alerts for CDC physicians.
“I think we’re making a big mistake,” Griffin said. “THE smallpox is likely already outside this target population and we’re letting it spread because we’re not willing to acknowledge it, because we’re not testing it, because our network isn’t broad enough.”
Other experts agree.
“I’m concerned that it has outgrown this community,” said David Hamer, an infectious disease specialist at Boston University who tracks the smallpox outbreak in international travelers through his GeoSentinel network of 71 locations around the world.
Hamer said that the outbreak appears to have been fueled by three mass gatherings in Europe ; at least one was a rave, where people contracted the virus and took it home. Most of these individuals were gay and bisexual men.
“But there are others who have clearly been infected, including some young children, and it’s not clear how they were exposed,” Hamer said.
One such case in the UK was a young child, “and they didn’t understand where and how that child acquired the infection,” he said.
“We need to think more broadly. We need to educate primary care providers to think about smallpox if they see someone with a rash,” Hamer said.
Modest demand for smallpox testing
At the beginning of the outbreak, doctors were allowed to test monkey pox only under a restricted set of circumstances, because testing capacity was limited to about 6,000 tests a week.
Recently, however, the CDC partnered with five commercial labs to scale up testing. When everyone has their programs running, they can process over 10,000 tests a day and 80,000 tests a week.
The expansion of testing to commercial labs makes the process of ordering these diagnoses much easier for doctors, but there is little indication that much testing is happening outside of sexual health clinics that primarily serve the LGBTQ community.
“Once it comes to commercial labs, we have a much more liberal ability to ask for it. No one is asking us to document any criteria or anything to order the test,” said Stacy Lane, medical director of the Central Outreach Wellness Center, which runs eight health clinics focused on LGBTQ wellness in Pennsylvania and Ohio.
While many of the commercial labs do not disclose the number of smallpox tests they are doing, there are indications that testing capacity is being underutilized.
A spokesperson for Quest Diagnostics, for example, said in an email that “we have modest demand, which continues to grow.”
Carlos del Rio, an infectious disease specialist at the Emory University School of Medicine, said he doesn’t think primary care providers are up to date.
“We need a lot more information and education for practitioners on how to use a test and what to do with it,” del Rio said. He added that his own friends and family were texting him with pictures of his injuries, asking if they could be smallpox.
Most of the time, he says, he assures them that what they have is probably not the disease. “I think it’s still pretty contained in the community of men who have sex with men,” del Rio said. “That doesn’t mean it’s going to stay there.”
The cost of misdiagnosis
Griffin said his patient has no idea how he was exposed and is now isolated in his basement. People with monkeypox are believed to be contagious for at least four weeks.
He is taking an antiviral drug called tecovirimat, which is being made available to monkeypox patients.
Doctors managed to vaccinate the patient’s wife and are carefully watching her children, including the baby, whom he held before he knew he was contagious.
Public health officials have recently expanded access to the smallpox vaccine from Jynneos monkeys to children under certain circumstances.
Griffin says that while the vaccine should be safe, there are no data on its use in children. Tecovirimat is also recommended for children under age 8, a group that the CDC says are most at risk for severe infection.
For now, the man is locked in his basement and unable to help around the house, which Griffin said has been difficult for him and his family.
“The father, who is very important in the first few weeks of the baby’s life, is now locked in the basement, which is tragic,” Griffin said. “You don’t have those weeks back.”
Source: CNN Brasil
