Video at https://www.youtube.com/watch?v=f8HRluqOqDg 🙈🙉🙊 We discuss the clinical features on the basis of a case series from the U.K. and then have a Q&A with pox virologist and UpToDate author on the topic, Dr. Stuart Isaacs. Discussant: Stuart N. Isaacs, MD; Perelman School of Medicine at the University of Pennsylvania Host: Benjamin P. Geisler, MD MPH Recording date: May 30, 2022 0:00 Intro 1:09 Outline and Study Type 2:13 Background 5:31 Case Series 11:39 Q&A w/ Dr. Isaacs References: -Case series: Adler H et al. Lancet ID online early doi: 10.1016/S1473-3099(22)00228-6 -Comparison to Covid-19 case report/series: Rothe C et al N Engl J Med. 382(10); 970-1 doi: 10.1056/NEJMc2001468 https://pubmed.ncbi.nlm.nih.gov/32003... -Dr. Isaac’s UpToDate article: -Microbe.TV: This Week in Virology (TWiV) Special: Monkeypox clinical update with Dr. Daniel Griffin https://www.youtube.com/watch?v=dMiT7... -Program for Monitoring Emerging Diseases (ProMED) Monkeypox update (06), 30 May 2022: https://promedmail.org/ -Centre for Infectious Disease Research and Policy (CIDRAP): WHO says monkeypox containable, but nations should be on alert. https://www.cidrap.umn.edu/news-persp... -Phylogenetic trees: Hendrickson RC et al. Viruses 2010(2); 1933-67. doi: 10.3201/eid2409.171283 https://pubmed.ncbi.nlm.nih.gov/30124... -Virion schematics: ViralZone, from https://commons.wikimedia.org/wiki/Fi... -Discussion of on-going MPXV genome sequencing: https://virological.org/t/discussion-... -Genomic epidemiology of monkeypox virus: https://nextstrain.org/monkeypox?l=clock #monkeypox #virus

2. Host: Benjamin P. Geisler, MD MPH Discussant: Stuart N. Isaacs, MD

3. Outline
1. Background
2. Case series (clinical features/management)
3. Q&A w/ Dr. Isaacs

4. Rothe C et al N Engl J Med. 382(10); 970-1

5. 1. Background
• Neglected tropical disease
• Zoonosis of an orthopoxvirus
• Reservoir: rodents?
• Transmission via direct skin contact or droplets (≥3h within 6’)
• Mortality: Central African > West-African clade (10% vs. <5%)
• Now: >300 cases in >20 countries
• One case at MGH; <10 HCWs vaccinated with Jynneos®
• Clinical features/management → case series
Sources: Dr. Isaac’s UpToDate article; Microbe.TV: This Week in Virology (TWiV); Program for Monitoring Emerging Diseases (ProMED); CIDRAP (Centre for Infectious Disease Research and Policy)

6. By Sequence
Extromelia
Cowpox (Ger/Brighton)
Tatera/camelpox, variola
Monkeypox
Cowpox (GRI)
Vaccinia
By Gene Content
Extromelia
Cowpox
Horsepox
Vaccinia
Variola
Tatera/camel/monkeypox
Hendrickson RC et al. Viruses 2010(2); 1933-67.

7. By Sequence
Extromelia
Cowpox (Ger/Brighton)
Tatera/camelpox, variola
Monkeypox
Cowpox (GRI)
Vaccinia
By Gene Content
Extromelia
Cowpox
Horsepox
Vaccinia
Variola
Tatera/camel/monkeypox
Hendrickson RC et al. Viruses 2010(2); 1933-67.

8. Source: ViralZone/WikiPedia

9. 1. Background
• Neglected tropical disease
• Zoonosis of an orthopoxvirus
• Reservoir: rodents?
• Transmission via direct skin contact or droplet (≥3h within 6’)
• Mortality: Central African > West-African clade (10% vs. <5%)
• Now: >300 cases in >20 countries
• One case at MGH; <10 HCWs vaccinated with Jynneos®
• Clinical features/management → case series
Sources: Dr. Isaac’s UpToDate article; Microbe.TV: This Week in Virology (TWiV); Program for Monitoring Emerging Diseases (ProMED); CIDRAP (Centre for Infectious Disease Research and Policy)

10. 2. Case Series

12. Methods
• All subsequent cases managed through the High Consequence
Infectious Diseases (airborne) network in Liverpool, London, and
Newcastle in the U.K. 8/2018-9/2021
• N=7
• Description of clinical features; PCR from ulcerated skin lesion; blood,
nose/throat, and urine; and response to off-label antivirals

13. Results – Baseline Characteristics

14. Results – Clinical Features

15. Results – Clinical Features

16. Results – Clinical Features

17. Results – Clinical Features

18. Results – Clinical Features

19. Results – Treatment

20. Take-Aways (From the Case Series)
• Direct contact, for example during or before/after sexual intercourse,
seems to be necessary for most transmissions
• Lesions on mucus membranes may also cause droplet transmission
• Skin lesions may (at first) be subtle, look at the entire integument incl.
palms and soles; PCR various tissues and fluids
• Brincidofovir may cause LFT elevation and may have to be stopped
• If severe pain, look for a deep abscess
• PPE and contact tracing per infection control
• Involve (sub)specialized teams

21. 3. Q&A w/ Dr. Isaacs

22. Discussant: Stuart N. Isaacs, M.D.
• Attended Brandeis and Yale School
of Medicine
• Trained at Temple, NIH NIAID, and
Tufts
• Heads a pox laboratory at Penn
• Associate Professor at the
Perelman School of Medicine
• Various leadership positions, incl.
Associate Dean
• ID Attending at Philadelphia VA
Medical Center