A computer rendering of monkeypox viruses.

Why the atypical symptoms in the latest Monkeypox cases?

In mid-May, a young man showed up at a Montreal hospital with a single lesion on his genitals. About a week earlier, he had sexual contact with someone who tested positive for monkey pox. Over the next few days, his lesion got bigger and more lesions appeared, but they weren’t painful. He had no fever and the lesion was limited.

This was one of the first cases of monkey pox in Canada. The details, including any atypical symptoms, were shared by one of the patient’s doctors, Sébastien Poulin, MD, of Saint-Jerome Hospital in Montreal, via Twitter

While monkeypox cases continue to rise in the US — with ten confirmed cases from Friday — questions are asked about the nature of the atypical symptoms that occur in different cases. Lack of fever or a penetrating rash, both of which are typically associated with monkey pox, do not occur in many cases.

Could this be a sign of a viral mutation in this monkeypox strain? Experts who spoke with MedPage today said not necessary.

Aaron Glatt, MD, the chair of the division of medicine and chief of infectious diseases at Mount Sinai South Nassau in New York, said the symptoms currently being reported are consistent with what we know about the virus. Monkeypox cases usually present with fever, rash and swollen lymph nodes, but these are not guaranteed to occur in all cases. He also pointed out that many reported cases appear to involve direct genital exposure to the viral lesions.

“That’s probably why you see a slightly skewed presentation, because there’s probably a direct inoculum in the general area, which has led to a very specific type of presentation,” Glatt said. “The critical factor is that there is nothing shocking or surprising here based on the events that occurred for these individuals.”

The ability of monkeypox to transmit from person to person has long been known, according to Grant McFadden, PhD, an immunotherapy, vaccine and virotherapy researcher at Arizona State University. The virus can spread through direct contact with the usual lesions, especially if they have broken open. He added that respiratory drops are also a known mode of transmission, but that would require prolonged, very close contact, similar to the sexual encounters reported in the cases in the US and Europe.

“There’s nothing magical about the biology of the virus,” McFadden said MedPage today† “There’s nothing magical about what we’re seeing in terms of the disease. What seems to be different is the way of close human contact, which seems to be the cause of this current outbreak.”

However, the atypical presentation of some of the symptoms suggests there is more to learn about this virus, according to Anne Rimoin, PhD, an epidemiologist at the University of California Los Angeles Fielding School of Medicine.

“Most of the knowledge we have is based on data from rural communities in Africa, or suburban communities, which are nothing like the communities it’s spreading into now,” Rimoin said. “So it’s important to treat this with care and caution and do the research needed to understand what we’re seeing now as opposed to what we’ve seen in the past.”

The virus hasn’t changed as much as the focus and location of the outbreak, Rimoin explains. She advised the medical community to remain humble and focus on understanding this virus as it exists. The best way to achieve that is by funding more research into this virus at home and abroad. In the meantime, however, she said there is more work to be done to contain this current outbreak, starting with identifying the undiagnosed cases.

“If you shine a flashlight in the dark, you will see something,” she said. “And we haven’t even used a pen light yet.”

McFadden emphasized the point that the infectious disease community is ready to deal with this outbreak, even as it is still being revealed. The decades of work developing the smallpox vaccine and its treatments have resulted in a stockpile of medical supplies that are almost perfectly geared to dealing with a monkeypox outbreak, he said.

The 2003 multistate outbreak of monkeypox in the U.S. — one driven by animal-to-human transmission, primarily from prairie dogs as pets — offers an important lesson, McFadden said. As cases began to appear in the Midwest, suspected doctors who knew the signs of the smallpox virus alerted state authorities of the concern, and the outbreak was detected and contained. The awareness of primary care providers helped identify and curb the spread of the monkeypox outbreak, and McFadden said that’s exactly what we need to do this time around, too.

“We have all the tools we need to nip it in the bud,” McFadden said. “The question is, will we get it right?”

  • Michael DePeau-Wilson is a reporter on the MedPage Today enterprise and research team. He covers psychiatry, long-term covid and infectious diseases, among other relevant clinical news from the US. Follow


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