By the time you read this, we’ll likely know the significance of yet another virus, monkeypox (MPX). Human MPX presents with a smallpox-like disease, as both are orthopoxvirus infections. The virus is transmitted by broken skin in close or direct contact, respiratory droplets or bodily fluids and is believed to be amplified by sexual transmission networks.^1-3 Incubation after exposure is possible up to three weeks (generally seven to 14 days). So far, there have been reported outbreaks in over 50 different countries, including the United States.² 

Background

Recent reports of an MPX outbreak or its uptick in humans suggest changes in biologic aspects (mutations) of the virus and possible changes in human behavior.^1,4 Unfortunately, transmission, risk factors, clinical presentation and infection outcomes are not well defined.² 

In one case series, monkeypox presented with a variety of dermatologic and systemic clinical findings.² The most common appears as initial skin lesion or lesions (macular, pustular, vesicular and crusted) primarily in the anogenital area, body or face, with the number of lesions increasing over time, either with or without systemic features.^2,3 Common systemic features during illness include fever, lethargy, myalgia and headache—symptoms that frequently precede a generalized rash.²

Identifying cases outside areas where monkeypox has traditionally been endemic highlights the need for quick identification to contain further spread.³ Although unusual rashes do not cover the full range of possible manifestations, monkeypox should be on a list of differentials.² 

Genital skin lesions and lesions involving the palms and soles may lead to misdiagnosis as syphilis or other sexually transmitted infections that could delay detection.^2,5 Throat or nasopharyngeal swab specimens taken from suspected skin or genital lesions are advised.² 

ODs on the Lookout

MPX virus is usually a self-limited disease with symptoms lasting two to five weeks, and supportive therapy is all that is necessary. Patients who experience more severe disease are or at risk for greater morbidity may be treated with oral antivirals such as tecovirimat cidofovir, brincidofovir and intravenous vaccinia immune globulin.^1,4,5 Data on effectiveness of any of these agents is limited. Containment is crucial and is accomplished by early identification. However, rapid identification is complicated by presentation of diverse signs and symptoms.^1-3,5 

Possible complications include periocular lesions, blepharitis, conjunctivitis and keratitis. Skin lesions around the eye may resemble varicella-zoster lesions.⁴ Focal lesions on the conjunctiva and along the lid margin are generally seen with greater frequency among unvaccinated patients with confirmed MPX virus (nearly 25%).⁴ Lymphadenopathy is a common finding similar to other viral diseases.⁴ 

MPX virus infection can result in severe corneal scarring that may require corneal trtansplantation.¹ Any ocular involvement is best managed with aggressive topical lubrication. Topical broad-spectrum antibiotics may be necessary for epithelial prophylaxis or bacterial superinfection.¹ Vaccinia is a similar viral infection, and reports suggest trifluridine may be helpful.¹

Healthcare in-office transmission prevention is similar to suspected COVID infections. Patients should be isolated. Healthcare providers should wear personal protective equipment, and slit lamp shields may help with any spread. Office surfaces should be cleaned with hospital grade disinfectant.⁶

As healthcare providers, we need to recognize dermatologic and systemic signs and symptoms in a timely fashion and treat appropriately any ocular complications that might accompany the monkeypox infection. Both MPX virus and COVID have viral vectors and meaningful ocular complications. Let’s hope this doesn’t grab a hold in our communities and instead passes more like “dust in the wind.”

1. Kaufman AR, Chodosh J, Pineda R: Monkeypox. EyeWiki. September 4, 2022. eyewiki.org/monkeypox. Accessed September 9, 2022.  2. Thornhill JP, Barkati S, Walmsley S, et al. monkeypox virus Infection in humans across 16 countries April-June 2022. N Engl J Med. 2022;387(8):679-91.  3. 2022 Monkeypox outbreak global map. Centers for Disease Control and Prevention. Last updated September 12, 2022. www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html. Accessed September 12, 2022. 4. Abdelaal A, Abu Serhan H, Mahmoud MA, et al. Ophthalmic manifestations of monkeypox virus. Nature. July 27, 2022. [Epub ahead of print]. 5. Grosenbach DW, Honeychurch K, Rose EA, et al. Oral tecovirimat for the treatment of smallpox. N Engl J Med. 2018;379(1):44-53. 6. Infection prevention and control of monkeypox in healthcare settings. Centers for Disease Control and Prevention. Last updated August 11, 2022. www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html. Accessed September 9, 2022.