仅当满足恰当的临床病例定义,且诊断通过实验室检测证实时,才能确诊。
若干非流行国家当前正在经历暴发。在评估有特征性皮疹者时,特别是当患者符合流行病学标准之一时,建议高度怀疑。由于此次暴发期间的临床表现可能不典型,当患者出现与性传播感染(sexually transmitted infection, STI)相关或类似 STI 的皮疹时,即使皮疹呈局限性而非(尚未呈)弥漫性,也应将猴痘纳入鉴别诊断。[62]Centers for Disease Control and Prevention. Clinician FAQs: questions and answers about monkeypox for healthcare professionals. July 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/faq.html
猴痘是应予通报的疾病,出现一例即被认为是暴发。应立即向国家或地区公共卫生机构报告疑似病例,无论是否正在探究其他诊断可能。
筛查和分诊
在进入卫生系统的第一个地点,对所有出现皮疹、发热或淋巴结肿大的人员进行筛查和分诊,以识别疑似或确诊感染者。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
在进入医疗机构时,可使用一份基于世界卫生组织(World Health Organization, WHO)病例定义(根据当地流行病学进行调整)的简化问卷和筛查方案。
进行筛查活动时,与患者保持至少 1 米的距离,并采用 "不接触 "的方式。在某些情况下,根据当地的路径,可使用远程医疗进行筛查。
将症状符合疑似感染病例定义的患者立即转至猴痘临床诊疗路径。向患者提供适配良好的面罩,将其隔离在通气良好的单人房间。
采用标准化分诊工具来分诊患者。
感染预防和控制
如果临床怀疑感染,应立即与所在地区传染病部门联系。
这将触发启动相关程序,从而将患者安全转移至负压隔离区,并通知公共卫生团队。
重要之处在于,对于与有症状患者密切接触的每一个体(例如家庭密切接触者、助理医护人员和医护人员)以及是否存在任何潜在的动物病毒携带者,均应进行记录。
所有疑似病例都应由包括公共卫生官员在内的专家进行管理,以防止出现潜在的紧急情况。
遵循当地感染防控常规。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
建议采取标准预防措施、接触传播预防措施和飞沫传播预防措施。
在照护疑似猴痘病例时,如果怀疑水痘,则推荐采取空气传播预防措施,直至排除水痘。当照护猴痘确诊病例时,推荐穿戴呼吸器。如果要实施产生气溶胶的操作,推荐采取空气传播预防措施。
将所有污染材料(例如,亚麻织物、病号服)以及患者的体液/固体废物作为具有潜在传染性的物品进行处理。
理想情况下,所有可能接触患者、体液或污染物的人员均应已接受天花疫苗接种。[63]World Health Organization. Monkeypox: fact sheet. May 2022 [internet publication].
https://www.who.int/en/news-room/fact-sheets/detail/monkeypox
对于未接种疫苗的接触者,可能建议进行暴露后预防(参阅预防章节)
如有可能,妊娠或免疫功能低下的医务工作者不应评估或护理疑似或确诊感染的患者。[64]UK Health Security Agency; Public Health Wales; Public Health Agency (Northern Ireland). Principles for monkeypox control in the UK: 4 nations consensus statement. July 2022 [internet publication].
https://www.gov.uk/government/publications/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement
病史
对于表现出不明原因急性皮疹的患者,尤其当患者在症状出现之前 21 日满足某一项流行病学标准时,应考虑该诊断。
流行病学诊断标准包括:[42]World Health Organization. Surveillance, case investigation and contact tracing for monkeypox. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2022.2
[65]UK Health Security Agency. Monkeypox: case definitions. July 2022 [internet publication].
https://www.gov.uk/guidance/monkeypox-case-definitions
[66]Centers for Disease Control and Prevention. Case definitions for use in the 2022 monkeypox response. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/case-definition.html
然而,不同地区的流行病学标准和病例定义存在差异。咨询当地公共卫生部门,以获取更多信息。参阅标准章节,获取病例定义。
临床表现
在潜伏期(范围 5-21 日),患者可能没有任何症状,并可能诉感觉良好。患者在出现特征性皮疹前,通常会出现前驱症状。
常见症状包括:[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
皮疹
发热
畏寒
淋巴结肿大
头痛
背痛
肌痛
咽炎
咳嗽
虚弱
恶心/呕吐。
较不常见的症状包括:[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
前驱期通常持续 1-5 日,患者在这期间可能有传染性。[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
目前没有证据表明患者在前驱疾病发作之前具有传染性。感染继续传播呈现最高风险是从前驱症状开始直至皮损结痂和脱落。[64]UK Health Security Agency; Public Health Wales; Public Health Agency (Northern Ireland). Principles for monkeypox control in the UK: 4 nations consensus statement. July 2022 [internet publication].
https://www.gov.uk/government/publications/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement
非流行国家多国疫情暴发(2022 年)
临床表现存在差异,许多病例未出现典型的临床表现。非典型情况下,全身症状可能出现在皮疹之后。[11]World Health Organization. Multi-country monkeypox outbreak: situation update. 27 June 2022 [internet publication].
https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396
部分患者可能无前驱症状。[67]Girometti N, Byrne R, Bracchi M, et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. Lancet Infect Dis. 2022 Jul 1 [Epub ahead of print].
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00411-X/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/35785793?tool=bestpractice.com
迄今为止,来自美国暴发的数据提示,最常见的症状有:[39]Minhaj FS, Ogale YP, Whitehill F, et al. Monkeypox outbreak: nine states, May 2022. MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):764-69.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7123e1.htm
http://www.ncbi.nlm.nih.gov/pubmed/35679181?tool=bestpractice.com
皮疹(100%)
乏力/疲劳(76%)
寒战(71%)
淋巴结肿大(53%)
头痛(47%)
发热(41%)
身体疼痛(35%)
咽痛或咳嗽(29%)
多汗(24%)。
已经制定该轮疫情暴发的特定病例定义,随着对疫情暴发调查的继续,这些病例定义可能出现改变。各地区病例定义有所不同。咨询当地公共卫生部门,以获取更多信息。参阅诊断标准章节,获取病例定义。
体格检查
体格检查通常会发现特征性皮疹,并且可能有淋巴结肿大。
水疱疹
前驱期后不久,会出现特征性皮疹。皮疹通常在急性发热性疾病出现后 1-3 日出现,通常在 24 小时内扩散至身体各部位。皮疹常累及手掌和足底。皮损同步经历 4 个阶段(斑疹、丘疹、水疱和脓疱),而后结痂并消退,通常需 2-3 周时间。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
病损在机体任何部位均呈现类似的成熟阶段,而且往往更集中于面部和四肢(离心分布),而非躯干。病损大小不一,直径 0.5-1 cm(但可更大),可能仅有数个或可有数千个。病损处可能有炎症,引起轻微发红和/或皮肤色素沉着过度,可能散在分布或融合。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
[63]World Health Organization. Monkeypox: fact sheet. May 2022 [internet publication].
https://www.who.int/en/news-room/fact-sheets/detail/monkeypox
[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
病损可能累及口腔黏膜(见于 70% 的病例)、生殖器(见于 30% 的病例)、结膜(见于 20% 的病例)以及角膜(眼球)。重症病例中,皮损可以融合,直到大片皮肤脱落。
在 2003 年美国疫情暴发期间,68% 的病例皮疹为单形性皮疹,29% 的病例皮疹为多形性皮疹,3% 的病例无皮疹。26% 的病例可见局限性病变;当广泛受累时,48% 的病例四肢受累更为明显,但 23% 的病例分布均匀,3% 的病例躯干受累更为严重。47% 的病例仅存在 5 至 25 处病损,33% 的病例存在 26 至 100 处病损,20% 的病例病损部位数量 >100。[29]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51.
https://academic.oup.com/cid/article/41/12/1742/344953
http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
已接种疫苗的患者和未接种疫苗的患者,其皮疹外观存在差异。已接种疫苗者病灶较少、较小,并呈现更明显的离心分布。[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
随着皮疹进展,斑疹在 1 至 2 天内发展为丘疹。丘疹随后另外耗时 1 至 2 天进展为小水疱。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
随着皮疹进展,小水疱可另外耗时 1 至 2 天进展为脓疱。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
当皮损变为脓疱时,出现第二个发热期,其与患者一般情况恶化具有相关性。[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
淋巴结肿大
淋巴结肿大可呈全身性,或者局限于若干区域。其通常伴随发热出现,在皮疹之前出现,或者罕见情况下,与皮疹同时出现。可出现于颌下、颈部、腋下或腹股沟,还可出现于躯体两侧或仅一侧。[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
肿大的淋巴结直径约为 1 至 4 cm,质地坚硬,伴触痛,有时可呈现疼痛。[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
淋巴结肿大是一种常见的鉴别特征,在患天花和鉴别诊断中的其他疾病时罕见。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[29]Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis. 2005 Dec 15;41(12):1742-51.
https://academic.oup.com/cid/article/41/12/1742/344953
http://www.ncbi.nlm.nih.gov/pubmed/16288398?tool=bestpractice.com
[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
[68]McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7.
https://academic.oup.com/cid/article/58/2/260/335791
http://www.ncbi.nlm.nih.gov/pubmed/24158414?tool=bestpractice.com
非流行国家多国疫情暴发(2022 年)
迄今为止,来自美国暴发的数据表明,淋巴结肿大(通常是腹股沟或颈部)常见(53%),皮疹发生在身体以下一个或多个部位:[39]Minhaj FS, Ogale YP, Whitehill F, et al. Monkeypox outbreak: nine states, May 2022. MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):764-69.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7123e1.htm
http://www.ncbi.nlm.nih.gov/pubmed/35679181?tool=bestpractice.com
手臂(53%)
躯干(53%)
腿部(47%)
面部(41%)
手部(35%)
肛周部位(35%)
口腔(29%)
颈部(29%)
生殖器(24%)
足部(24%)。
多数病例生殖器或肛周区域病损更为密集,提示传播发生于性交期间。[67]Girometti N, Byrne R, Bracchi M, et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. Lancet Infect Dis. 2022 Jul 1 [Epub ahead of print].
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00411-X/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/35785793?tool=bestpractice.com
[69]European Centre for Disease Prevention and Control. Monkeypox cases reported in UK and Portugal. May 2022 [internet publication].
https://www.ecdc.europa.eu/en/news-events/monkeypox-cases-reported-uk-and-portugal
[70]Patrocinio-Jesus R, Peruzzu F. Monkeypox genital lesions. N Engl J Med. 2022 Jul 7;387(1):66.
https://www.nejm.org/doi/10.1056/NEJMicm2206893
http://www.ncbi.nlm.nih.gov/pubmed/35704421?tool=bestpractice.com
非典型表现包括:[11]World Health Organization. Multi-country monkeypox outbreak: situation update. 27 June 2022 [internet publication].
https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396
这种表现可能很容易与 STI 相混淆。
[Figure caption and citation for the preceding image starts]: 个别病损的图片(非流行国家多国疫情暴发)UKHSA [Citation ends].
疾病严重程度和重度疾病的危险因素
多数病例较轻,然而疾病程度可呈轻重各异,甚至可致死。
疾病严重程度取决于患者最初健康状况、既往疫苗接种情况、是否具有合并症、暴露途径和病毒株。[37]Centers for Disease Control and Prevention. Monkeypox: clinical recognition. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
[48]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of monkeypox. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
与中非进化枝相比,西非进化枝与较轻的疾病程度具有相关性。[6]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577
http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com
无症状感染已得到描述,但无症状感染可能呈现的疾病严重程度尚不明确。[41]Fenner F, Henderson DA, Arita I, et al. Chapter 29: Human monkeypox and other poxvirus infections of man. In: Smallpox and its eradication. Geneva: World Health Organization; 1988.
http://apps.who.int/iris/handle/10665/39485
[63]World Health Organization. Monkeypox: fact sheet. May 2022 [internet publication].
https://www.who.int/en/news-room/fact-sheets/detail/monkeypox
过去进行疫苗接种所获免疫力极大降低了临床征象和症状的发作频率及强度。[6]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577
http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com
评估患者,确定其是否存在重度疾病或有并发症疾病的症状和体征。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
并发症的临床症状和体征:
恶心和呕吐
有疼痛的颈部淋巴结肿大引起吞咽困难
经口摄入不足或脱水
眼睛疼痛或视力异常
肝肿大
脓毒症
呼吸窘迫/肺炎
意识模糊。
实验室检查结果异常:
肝脏转氨酶升高
低血尿素氮水平
低白蛋白血症
白细胞增多
血小板减少。
皮损严重程度评分:
轻度(<25 个皮损)
中度(25-99 个皮损)
重度(100-250 个皮损)
极重度(>250 个皮损)
在英国,重度疾病的界定依据为:[71]NHS England. Monkeypox. July 2022 [internet publication].
https://www.england.nhs.uk/publication/monkeypox
伴严重临床疾病的成人(例如国家早期预警评分 [National Early Warning Score, NEWS] 2 评分 ≥5),可包括显著下呼吸道症状、意识模糊/脑炎和其他并发症(例如继发性细菌感染、脓毒症)
数量很多的广泛播散性病损(≥100)
疑似角膜感染
病损所致严重难治性疼痛需要住院治疗,才能达到症状控制
病损伴疼痛或肿胀所致并发症(例如,便秘、尿潴留、无法吞咽)
免疫功能低下者、孕妇或 ≤16 岁儿童中的确诊感染,无论严重程度如何。
在美国,重度疾病的界定依据为患者存在以下情况:[48]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of monkeypox. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
融合病损
脓毒症
脑炎
出血性疾病
任何需住院治疗的其他疾病。
评估患者,确定其是否存在任何危险因素。有较高重度疾病或并发症风险的患者组包括:[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[48]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of monkeypox. June 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
[71]NHS England. Monkeypox. July 2022 [internet publication].
https://www.england.nhs.uk/publication/monkeypox
初始检查
确定性诊断需要实验室确诊。地区公共卫生实验室可进行检测。
对于疑似感染的患者,应尽快实施检测。[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. June 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
对于所有符合病例定义的个体,均应给予检测。[72]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1
应基于临床和流行病学因素(与感染可能性评估相关),确定是否检测
在鉴别诊断中,与猴痘检查同时进行其他疾病诊断性检查。[73]UK Health Security Agency. Monkeypox: diagnostic testing. July 2022 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
在患者检测结果出来之前,仍应隔离患者。
使用实时聚合酶链反应(real-time polymerase chain reaction, RT-PCR)或传统 PCR 的核酸扩增检测(nucleic acid amplification testing, NAAT),鉴于其准确性和敏感性,为首选实验室检查。[72]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1
[73]UK Health Security Agency. Monkeypox: diagnostic testing. July 2022 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
推荐样本类型为皮损组织,包括皮损渗出物拭子、一个以上皮损的病灶组织,或皮损结痂。[72]World Health Organization. Laboratory testing for the monkeypox virus: interim guidance. May 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-laboratory-2022.1
样本类型可能因皮疹分期不同而有差异。
根据参考实验室工作流程,采集其他诊断标本,例如口咽拭子、加入乙二胺四乙酸(ethylenediamine tetra-acetic acid, EDTA)的血样以及尿液。
建议对确诊病例的高危接触者进行口咽拭子采样,这些接触者已出现全身症状,但没有皮疹或病损可供采样。[73]UK Health Security Agency. Monkeypox: diagnostic testing. July 2022 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
根据地区或国家操作常规,进行样本采集、包装和送检。样本送检之前,将猴痘可能性通知实验室。关于实验室安全处理此类标本,以及将此类病毒学样本进一步转送至参考实验室,已有当地规程可供参考。将用于检测其他感染的样本单独包装。
还需对患者进行常规血液检验,包括:
其他检查
如果怀疑皮肤病灶存在细菌超级感染,或怀疑体弱患者存在细菌感染,则应在患者处于隔离状态时,且在给予抗生素治疗前,进行血培养。
血清学和抗原检测目前不建议用于诊断。
对于任何到过疟疾流行地区的发热患者,尤其是在发热之前 3 周内去过疟疾流行地区的患者,始终应排除疟疾混合感染的可能性。抗原检测给实验室工作人员带来的感染隐患小于制备厚血膜涂片和薄血膜涂片带来的隐患。
鉴别诊断
这种皮疹可能与临床实践中更常遇到的其他疾病的皮疹相混淆。
非流行国家多国疫情暴发(2022 年)
CDC 已经发布对临床医生有帮助的技术报告,包括与猴痘相关的皮疹图片以及常见鉴别诊断的相关皮疹图片。