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July 2003 • Volume 37 • Number 7

News

Scattered lesions at varying stages
Monkeypox Far Different From Varicella or Smallpox, Doctor Says

Timothy F. Kirn
Sacramento Bureau

The first case of monkeypox virus infection to be identified in the United States did not fool Dr. John W. Melski into first mistaking it for chickenpox, or cause him undue alarm that it was smallpox.

The presentation of the 4-year-old girl, who had been bitten on the finger by a pet prairie dog, was obviously the result of a disseminated viral illness. There was fever, an exanthem, and lymphadenopathy. But the lesions were distinctly different from those in chickenpox or smallpox, said Dr. Melski, a dermatologist at the Marshfield Clinic, the central Wisconsin clinic where the child was seen.

“There were never as many lesions as [with] chickenpox,” he said in an interview. “And, there was not the desperate illness one sees with smallpox.”

Also, the lesions seen on the child, and on her parents who also became ill, were more scattered than those caused by smallpox, and tended to be in varying stages of development, Dr. Melski said. Smallpox lesions tend to appear in regional clusters, and usually all of the lesions in a cluster are in the same stage of progression as they go from papules to edematous papules, to vesicles, to pustules, and finally crust over.

Dr. Melski also noted that the bite wound—the presumed initial site of infection in the child—developed a whitish rim about 4 days after the child became ill. The pustules eventually umbilicated before crusting over, and an eschar was seen in some lesions. The child's lesions were restricted to the extremities and the perineum; the mother's lesions were on the extremities and also the trunk.

In the cases of monkeypox reported to date, the typical illness has consisted of a prodrome with fever, headaches, myalgias, chills, and drenching sweats. About one-third of the reported cases have had respiratory symptoms and a nonproductive cough.

Many patients had the initial lesions on the palms and soles, and some lesions have been on the head.

All the patients identified as of mid-June reported close contact with pet prairie dogs, which appeared to have come from the same Chicago-area exotic animal distributor.

The prairie dogs probably acquired the infection while with the distributor, through contact with a Gambian giant pouched rat.

Most of the animals have appeared ill, and the illness was said to start as a blepharoconjunctivitis.

The average incubation period for the illness in humans appears to be about 10-12 days. But the child seen by Dr. Melski first became ill on May 16, just 4 days after the animal was acquired by the family; the father, who was the last family member to become ill, first had symptoms on May 31.

Dr. Melski said that before he knew that the patients had monkeypox, the child received intravenous acyclovir in the hospital and the mother received valacyclovir for a day. The antiviral therapy was stopped when the illness was identified as monkeypox.

Officials from the Centers for Disease Control and Prevention currently are not recommending a specific treatment for monkeypox-infected individuals.

It is presumed that the only antiviral drug that is likely to have any activity against monkeypox is cidofovir, but research is still underway.

The agency advised physicians not to treat patients with cidofovir except in life-threatening situations.

Most cases of monkeypox to date have occurred in rural Africa, and no information is available on how the infection can complicate pregnancy.