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Mr. Nacinovich:
As monkeypox continues to spread across the globe, new symptoms continue to emerge. How should we approach tackling these new manifestations? And what do they tell us about the evolution of this global outbreak?

Welcome to Clinician's Roundtable on ReachMD. I'm your host, Mario Nacinovich, and here with us are two authors to share their insights on monkeypox: Dr. Aatish Patel and Dr. Julia Bilinska. Dr. Aatish Patel is an infectious disease physician at Guy's and St. Thomas' NHS Foundation Trust in London. Dr. Patel, welcome to the program.

Dr. Patel:
Hi, Mario. Thanks for the introduction.

Mr. Nacinovich:
And Dr. Julia Bilinska is a physician in the Department of Sexual Health at Guy's and St. Thomas' NHS Foundation Trust in London. Dr. Bilinska, thanks for being here today.

Dr. Bilinska:
Thank you very much for inviting us.

Mr. Nacinovich:
So let's start with you, Dr. Patel. What are some of the most common manifestations of monkeypox that you've seen in your patients?

Dr. Patel:
So the study that we did was based in a single center in London and that's a city which has seen approximately 75 percent of cases in the UK. And the patients that we manage were mostly seen through sexual health and HIV clinics but also through emergency departments and direct admissions to our infectious diseases ward. And what we were seeing was a mixture of clinical presentations that fit with what we previously knew about monkeypox from previous outbreaks in endemic regions, such as West Africa, but also features that appeared quite different. So, looking at the cohort that we managed, all the patients had mucocutaneous lesions at the time of presentation, which I guess is not surprising, as this is likely sort of the trigger for a patient to attend healthcare services, especially as the understanding of monkeypox grew within communities, and we were seeing that as opposed to people coming in with general systemic symptoms. The majority of these patients with mucocutaneous lesions had them on their genitals or perianal area, but we did also see patients with them on their face, trunk, limbs. And on average, people were presenting with approximately six lesions sort of at the time of presentation, so not really as many as what we've seen in previous outbreaks or what's been documented in previous outbreaks.

A majority of patients did have some systemic signs, so most commonly fever and lymphadenopathy, and myalgia at some point in their, in their illness, but significantly, I think, almost 15 percent had none of these symptoms at the time of presentation. So as well as these sort of recognized signs and symptoms as I've just mentioned, we've seen presentations either not previously described or not thought to be typical of monkeypox, and this includes, rectal pain, penile edema, tonsillar signs, so sort of lots of erythema or exudates or abscesses in the tonsil, in and around the tonsils. And some patients with these symptoms develop quite significant complications.

Mr. Nacinovich:
So moving to you, Dr. Bilinska, can you give us some background on your study and perhaps maybe even the genesis of it when you and Dr. Patel determined this is something new, this is nothing we need to be reporting on, this is something we need to be developing as a study?

Dr. Bilinska:
So, in May, it became very clear that community transmission of monkeypox was not only established but escalating in the UK, and the team of clinicians behind the project that Aatish has described is made up of infectious diseases and HIV and sexual health specialists, all of whom have been managing patients with monkeypox in a large center treating a high volume of cases from the very beginning of this outbreak. Our team were in regular contact with patients, who described anger, fear, isolation, and there really was a recurring theme. Why haven't they heard about the symptoms they were suffering from?

Aatish mentioned already we saw several clinical trends that had unusual presentations and differed previously reported features from past monkeypox outbreaks, and many had seen multiple healthcare professionals and received treatment for other infections, such as bacterial tonsillitis, prior to even being considered for testing for monkeypox.

So, really, our aims were simple. We wanted to raise awareness of the clinical manifestations of monkeypox in this outbreak, including the less common presentations, we wanted to improve public health messaging, and we wanted to advocate for the people at the highest risk of being exposed to monkeypox.

Mr. Nacinovich:
Dr. Patel, when we think about the original clinical manifestations of monkeypox decades ago in the Congo versus what the clinical manifestations are of monkeypox in the current outbreak, how would you compare and contrast the two?

Dr. Patel:
Yeah. I think that's a really interesting question. I think transmission in the previous outbreaks were predominantly through animal to human. We didn't see much human to human. But, of course, in this current outbreak, there's overwhelming evidence to suggest human-to-human spread.

There's sort of elements of the signs and symptoms and sites of lesions that could be explained by the differences in the outbreaks. And currently, we're seeing predominantly genital and perianal lesions, and this is likely to be associated with the sort of site of inoculation, whereas in previous endemics in West Africa, it was mostly sort of hands and face but I think there's features within this outbreak that are suggesting sort of a potential change in the natural history of the virus as we previously knew it. We're also seeing sort of biphasic appearances of lesions. So there's the initial lesions at the site of inoculation and then sort of further dissemination of lesions to different parts of the body days later, and so this sort of polymorphic rash so where the rash is present at different stages of evolution but at the same time point. And if we take a few of these, for example, single lesions or, um, atypical lesions, such as tonsillar signs, for example, you can see how sort of many of these may have been sort of misdiagnosed in the community, and that could explain why the current outbreak was so widespread at the time of detection.

Mr. Nacinovich:
For those just tuning in, you're listening to Clinician's Roundtable on ReachMD. I'm Mario Nacinovich, and I'm speaking with Dr. Aatish Patel and Julia Bilinska about their recent publication in BMJ that looked at clinical symptoms of monkeypox in a recent London outbreak.

Staying with you for a moment, Dr. Patel, from your vantage point, what should physicians now be looking for when identifying and diagnosing patients?

Dr. Patel:
Yeah. So I think at this stage of the outbreak, clinicians need to sort of be quite open-minded and maintain a high level of suspicion, particularly sort of in at-risk individuals. There's an increasing body of work referencing clinical presentations from sort of the typical to the more atypical signs and symptoms of monkeypox, so it's good for ID physicians, for dermatologists, for surgeons, probably even dentists, essentially the whole healthcare network to really inform themselves, because I think, as we've learned from COVID, pandemics sort of tend to affect everyone one way or the other.

I think it's important to appreciate there's a lot that we don't sort of understand yet, and that means expect the unexpected. At least while we're learning more and more we have to sort of move away from the concept of classical monkeypox, and so I guess what I mean by that is we're seeing atypical features. From a clinical context, sort of within patients who have confirmed monkeypox, I think one of the most common reasons we had for admission was severe rectal pain and penile edema, and I think based on that, I think it would be pertinent that if there were patients who present with erectile or anal, or penile lesions, that may be considered for regular review or for even inpatient management. And I think although tonsillar lesions and abscesses were not common in patients that we saw, it obviously introduced the risk of airway obstruction and so, of course, this is extremely important to be alert for.

Mr. Nacinovich:
Turning now to you, Dr. Bilinska, how should we be talking to our patients about their potential risk and what signs and symptoms of monkeypox they should be on the lookout for?

Dr. Bilinska:
From our experience at our center, we observed skin lesions could often occur at sites associated with recent sexual contact, and a newly published Italian study has confirmed replicating virus in semen. The real complicating factor here is that only a quarter of our cohort had known contact with someone with symptoms or confirmed monkeypox on retrospective review suggesting that some people could be asymptomatic carriers of monkeypox, and then other symptoms could be mild, almost unnoticeable, and these factors are undoubtedly contributing to the ongoing community transmission. So, when thinking about risk of exposure, close physical and sexual contact is currently the most significant. Saying this, it doesn't just apply to people who have frequent partner change or multiple partners. Many of our cohort only had a single recent partner. So people need to be aware of the variety of clinical presentations, including the spectrum of skin lesions, perianal, rectal, genital and throat symptoms.

Mr. Nacinovich:
Dr. Bilinska, I wanted to follow up with you on one item, certainly in terms of the potential risk and signs and symptoms with patients. How can we help educate the general public who may not be exposed to monkeypox in any way? How can we help destigmatize monkeypox in your mind?

Dr. Bilinska:
I think that's an excellent question, and in truth, I think it's kind of multipronged. So, as you said, it's the general public. We need to disseminate factual information which technically shouldn't stigmatize.

So I think the key to combating the societal stigma is education, clear information, evidence-based information that we're disseminating, but it needs to be on the big media outlets kind of going out to every single person, as we said, reaching people who may not feel that they are at risk or have come into contact with monkeypox.

Mr. Nacinovich:
And, finally, I want to give you each an opportunity to share any final thoughts, starting with you, Dr. Bilinska. Do you have any key takeaways you'd like to share?

Dr. Bilinska:
So we observed a spectrum of clinical presentations, and both the public and clinicians need to be aware of these to ensure that we can promote earlier diagnosis, treatment, and ultimately minimize onward transmission of monkeypox. It's important for us to promote the idea that monkeypox can present with mild symptoms, but some people can experience severe pain or develop secondary infections or complications, and they might require more regular review or even a hospital admission. And then I think my last thoughts are that I do think we still have the opportunity to deescalate this outbreak through improving, testing, promoting prevention strategies and more targeted vaccination programs, and saying that feels like we have a lot of work left to do.

Mr. Nacinovich:
I would absolutely agree. And, Dr. Patel, I'll turn to you with the same question.

Dr. Patel:
Yeah, and I think I echo everything that Julia has just said and, you know, and reiterate the importance of us as clinicians and not just—again, I mentioned this before—but not just ID physicians but the whole healthcare sort of family: surgeons, family practitioners, dentists, all really taking the responsibility of informing themselves and learning about monkeypox because I do feel that this has already been seen to present in various different parts of healthcare services. They're in primary care, secondary care, within medicine, within surgery. And again, in order to be able to recognize and therefore minimize transmission and improve patient outcome, it's really our responsibility as clinicians to make sure we're doing what we can to sort of pick up these signs and symptoms.

Mr. Nacinovich:
As we come to a close, I would love to thank you both for joining me today and providing your perspectives on the monkeypox virus. Thank you both, Dr. Patel, Dr. Bilinska, for being here with us today.

Dr. Patel:
Thanks for having us.

Dr. Bilinska:
Thank you very much for inviting us.

Mr. Nacinovich:
I'm Mario Nacinovich. To access this and other episodes in our series, visit ReachMD.com/CliniciansRoundtable where you can be Part of the Knowledge. Thanks for listening.