Second probable Monkeypox case in King County and updated case-finding guidance

Actions requested

• Report suspected cases of monkeypox immediately to Public Health – Seattle & King County (PHSKC) at 206-296-4774
• Be aware that the clinical presentations of confirmed cases in the U.S. to date differ from the classic presentation of monkeypox in prior outbreaks
  • While classic monkeypox has been characterized by a prodrome including fever, headache, malaise, and lymphadenopathy prior to vesiculo-pustular rash onset, patients in this outbreak have not always experienced these symptoms prior to rash, if at all
  • All patients diagnosed with monkeypox in the U.S. have experienced a rash or enanthem, however, the lesions have sometimes been small, in low numbers, and in different stages of progression on a specific anatomic site (e.g., vesicles and pustules existing side-by-side) 
  • Patients in this outbreak have often presented with rashes beginning in mucosal areas (e.g. genital, perianal, oral mucosa) and lesions have been both scattered or localized to a specific body site, rather than the typical diffuse rash beginning with the face seen in the classic presentation of monkeypox
  • Some patients have presented with symptoms of anorectal pain, tenesmus, and rectal bleeding, with visible perianal lesions found upon further examination
  • The clinical presentation of monkeypox may be similar to some STIs, such as syphilis, herpes, lymphogranuloma venereum (LGV), or other etiologies of proctitis, and diagnosis of an STI does not exclude monkeypox, as a concurrent infection may be present
  • The current CDC case definition notes that any person presenting with a new characteristic rash without an alternative diagnosis that can fully explain the illness, or that meets epidemiologic criteria with a high clinical suspicion for monkeypox, should be evaluated as a suspect case
• Collect specimens from at least two lesions for testing at Washington State Public Health Laboratory (WAPHL)/CDC and coordinate through PHSKC at 206-296-4774
  • Send separate swabs from at least 2 lesions in individual vials, preferably 3 or more swabs
  • In addition to dry swabs, CDC can now accept lesion swabs in viral transport media and lesion crusts. These two specimen types must be received by CDC within 7 days of collection.
  • Refer to CDC’s specimen collection webpage for the most up-to-date guidance
  • Clinicians should consider collecting case information using the Washington Department of Health Suspect Monkeypox Intake Form. This information will help aid PHSKC in determining whether to move forward with testing.
• Specimens should now be shipped Category B, once approved by PHSKC
  • DOT has amended guidance to allow Category B shipment of suspect Monkeypox specimens. All diagnostic samples approved for testing at WAPHL Laboratory are now able to be packaged and shipped as “UN 3373 Biological Substance, Category B”.
  • Each specimen should be appropriately labeled and accompanied by a completed WAPHL Bioterrorism Laboratory Requisition Form
  • Information on acceptable specimen types, storage conditions, and the accompanying submission requisition can be located on the WAPHL Lab Test menu