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Basgoz and her colleagues at the hospital tested the patient for chickenpox. He was negative. They tested him for syphilis. He was negative.
Doctors were still treating him with antibiotics and antivirals used for common infections while awaiting his various test results – but his condition did not improve in response to those treatments.
As the days went by, Basgoz noticed that the patient’s rash was changing. In that moment she knew that he had no ordinary illness.
Her mind was racing, putting pieces of a medical puzzle together.
“The combination of the lack of improvement when treated for common things, the negative results of tests for common infections, and some change in the appearance of the rash – all pointed to the possibility that this could be a smallpox virus,” she said. That was her aha moment.
Why the symptoms appear more subtle in the current outbreak
Monkeypox “wasn’t on our radar screen initially,” Basgoz said of the handling of the first US case.
As the monkeypox virus spreads, some doctors and public health officials have noticed that patients are exhibiting milder symptoms that could be mistaken for other illnesses. Two factors could explain why the disease sometimes shows up in more subtle ways, Basgoz said.
“The second so far is that among the reported patients are a large number of relatively young and otherwise healthy individuals,” Basgoz said. “When you see infection in relatively young and otherwise healthy people, it’s often milder than in older people or people with other medical conditions.”
The CDC has said the risk to the general public remains low, but health care providers should be vigilant for patients who have a rash or illness consistent with monkeypox.
“Historically, people with monkeypox have reported flu-like symptoms such as fever, body aches, and swollen glands, before a characteristic, often diffuse, rash appears on multiple parts of the body, often on the face, arms, and hands. But during the current outbreak, some patients have developed a localized rash, often around the genitals or anus, before they have even had any flu-like symptoms, and some have not even developed such flu-like symptoms,” said CDC Director Dr. Rochelle Walensky in a news briefing on Friday.
She added that in some patients, the rash doesn’t always spread beyond its original location to other parts of the body, or it appears in only a few areas of the body.
“The lesions themselves can be confused with the lesions of herpes, chickenpox, or syphilis, and that’s why STD clinics may see more of these patients because they can present similarly to those diseases,” Wojewada said. “So I think it’s important for both patients and doctors to provide a full history of your potential exposures so that testing for monkeypox can be done, if necessary.”
Elevated monkeypox testing required
The 45 monkeypox patients identified so far in the United States are in 15 states and Washington, DC, and the virus does not appear to be spreading in “a specific area” of the country, a CDC official said in Friday’s news briefing .
“We have not currently identified any area in the United States that appears to be having an urban outbreak, as has been reported for Montreal and some other locations. We don’t have an area where there appears to be a lot of community transmission,” said Dr. Jennifer McQuiston, a veterinarian and associate director of the CDC Division of Pathogens and Serious Consequence Pathology, in the briefing.
Most cases in the United States — 75% or more — still report they may have been exposed to the virus during international travel, McQuiston said. A few other patients have reported contact with a known case of monkeypox and they have been identified through contact tracing.
But there are also some patients who are unsure how they contracted monkeypox, “and this may indicate that community transmission is occurring at levels below what public health officials are aware of.” will,” McQuiston said.
“There’s just those occasional cases where it’s not clear how they contracted monkeypox,” she added. “Most likely they acquired it from someone who has traveled recently, but they just aren’t sure – and that’s the situation we’re in in the US right now. That could change. We could start spreading the community and I think we need to make sure that our testing increases and that we’re able to spot it when it happens.”
“The high proportion of first-time cases diagnosed in this outbreak among people who identify as gay, bisexual or other MSM may simply reflect an early introduction of monkeypox into interconnected social networks; this finding may also reflect a bias in the finding due to strong, established relationships between some MSM and clinical providers with robust STI services and broad knowledge of infectious diseases, including uncommon conditions,” CDC researchers wrote in the report.
“However, infections are often not limited to specific regions or population groups; because close physical contact with infected individuals can spread monkeypox, any person, regardless of gender or sexual orientation, can contract and spread monkeypox.”
Basgoz of Massachusetts General Hospital hopes that while people know what monkeypox symptoms can look like in this outbreak, they understand that the risk is small and don’t stigmatize the disease.
After all, viruses are all around us, she said, and trillions of microorganisms even live inside our bodies without us realizing it, with viruses outnumbering bacteria.
“They’re everywhere,” Basgoz said. “Most of them don’t make us sick, but occasionally they do, and so I really like to put that in context for people.”
CNN’s Michael Nedelman contributed to this report.
