Case history

Case history

A 25-year-old anthropologist was working in a remote part of the Democratic Republic of Congo. She arrived in the UK a week later, and developed a fever 2 days ago. She is still taking doxycycline malaria prophylaxis, but is nevertheless concerned that she might have malaria. She is taking no other medication. She complains of rigors, chills, and a scanty generalised blistering rash. She states that she had chickenpox as a child, and that two of the children in the compound where she was staying had a similar rash and were unwell when she left. Her vesicles are all at the same stage of development, and are more numerous on her face and limbs than her body. Clinically, monkeypox is suspected given the appearance of the rash and the epidemiological link with Central Africa, so the regional infectious diseases unit is contacted and the ambulance service alerted of the infection risk. On arrival in hospital she is immediately placed in isolation and staff wear full personal protective equipment. The history is confirmed, there are no drugs apart from malaria prophylaxis, and a list of contacts taken. She has never been vaccinated against smallpox. Baseline observations are performed, including blood pressure and oxygen saturation. The patient is pyrexial (38.5°C [101.3°F]), mildly hypotensive with a blood pressure of 100/60 mmHg, and tachycardia of 90 bpm, so intravenous fluids are commenced. Physical examination is remarkable for the presence of rash and cervical/axillary lymphadenopathy. The hospital laboratory is contacted in advance to warn of high-risk specimens for processing. The rare and imported pathogens laboratory is contacted to warn of incoming high-risk specimens and to seek latest advice on desirable materials for collection. The public health doctor on call is notified. Vesicle fluid is collected on a sterile virological swab and placed in a sealed container. Blood is collected for full blood count, urea and electrolytes, liver function tests, lactate, ethylenediamine tetra-acetic acid (EDTA) blood for polymerase chain reaction (PCR) studies, blood cultures, plain serum for serological studies, and an urgent malaria film. A throat swab and a urine specimen are collected for virological studies, and a urine pregnancy test is performed with the patient’s consent. The specimens are safely transported to the laboratories as per protocols. Paracetamol is given for fever, and blood pressure improves to 110 mmHg systolic following 500 mL of normal saline, so antibiotics are withheld and catheterisation deferred. Blood tests reveal a negative malaria film, a mild thrombocytopenia, mild lymphopenia, normal urea and electrolytes, and normal lactate. It takes 24 hours for the vesicle fluid PCR to be processed, which reveals monkeypox DNA. The patient remains clinically stable and a decision is made to withhold investigational antiviral agents, but close contacts are offered smallpox vaccination after counselling regarding risks and benefits.

Other presentations

There is currently an ongoing outbreak across several countries. The clinical presentation of confirmed cases has been variable, but many cases in this outbreak are not presenting with the classical clinical picture. The following case history is specific for the current ongoing multi-country outbreak.

A 32-year-old man has a genital rash that started 8 days ago as painless white pustules on his penis, and subsequently became painful and itchy. He reports recent travel within Europe where he had unprotected insertive anal intercourse with two different casual male partners. The rash started approximately 5 days after these encounters, and subsequently spread to his trunk, face, and hands. The man reports fever, swollen glands, and feeling very unwell starting 3 days after the appearance of the rash. On examination, the lesions on his genitals appear to be crusted over, while the lesions on his face, trunk, and limbs are sparse but in multiple stages of evolution (lesions are in the papular, vesicular, and pustular phases). Routine blood tests are normal. Real-time polymerase chain reaction assays for varicella zoster virus, herpes simplex virus, Chlamydia trachomatis, and Neisseria gonorrhoeae are all negative. Syphilis serology is also negative. Monkeypox is suspected; specimens are collected and sent for laboratory testing.

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