Not always mild: What physicians are seeing among monkeypox patients

While the hospitalization and death rate for monkeypox are very low, some physicians are surprised by the severe pain symptoms are causing infected patients. 

"The biggest misconception is that this is always a mild disease," Jason Zucker, MD, an infectious diseases specialist at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City, said during an Aug. 5 call with reporters. 

Globally, five deaths among patients who contracted the disease amid the current outbreak had been reported as of July 22, according to a World Health Organization report published July 25. A global study involving 528 people infected with monkeypox between late April and June 24 found 70, or 13 percent, were hospitalized, mostly for pain management, according to findings published July 21 in The New England Journal of Medicine. 

Most patients in New York City, an epicenter of the outbreak, are recovering at home with outpatient supportive care, Dr. Zucker said. They're experiencing some symptoms that present with many other viral illnesses, such as fever, chills and swollen lymph nodes, in addition to a rash that develops a few days after the other symptoms. He said there's been a "small number" of patients whose symptoms were severe enough to require hospitalization. 

"For a percentage of patients, it's not mild and is much more severe than I would've anticipated," Dr. Zucker said. Swollen lymph nodes make it hard to swallow, and some patients who develop urethral lesions report extreme pain every time they urinate. "Maybe what we're seeing most commonly [is] patients presenting with severe rectal pain and bleeding everytime they go to the bathroom," Dr. Zucker said. "For patients with these symptoms, it's an extremely severe disease."

Mary Foote, MD, medical director at the New York City Department of Health and Mental Hygiene, described the same observations during a media briefing in mid-July. "We've seen many people with symptoms that are so severe that they are unable to go to the bathroom, urinate or eat without excruciating pain," she said. 

Based on anecdotal observations, Dr. Foote said the clinical response to tecovirimat, or Tpoxx — an investigational drug only available through an expanded access program through the CDC — has been good, with patients reporting significant improvements in their symptoms within a few days. However, it's a difficult treatment to come by, with patients unsure where to go and physicians having to go through a lengthy process to obtain a prescription. 

"Just to put it in perspective, from my conversations with some of our treatment providers, between all the forms and administrative requirements, a patient visit to initiate tecovirimat  can take anywhere between one and a half and three hours," Dr. Foote said. With many patients being seen in busy urgent care centers and hospital EDs, this has been "nearly impossible to implement." 

"It's really been striking to me how many of these patients have had difficulty getting the care they need to treat these symptoms — having to go between clinics, hospitals, urgent cares," Dr. Foote said. 

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