When the man came into Mass. General in mid-May, it was immediately obvious he was sick and in pain, but with what?

In a recent paper in the New England Journal of Medicine, several doctors at the hospital collaborated to describe the US's first monkeypox case this year, how they diagnosed it, and the way the hospital and the state mobilized to respond to it (note: The report has several photos of the unnamed patient's sores).

In early May, the man, from a Boston suburb, went to another hospital's primary-care clinic for treatment of white "bumps" that had turned into "ulcerative lesions" after returning from a trip to Montreal. Doctors there performed tests for HIV, syphilis, gonorrhea and chlamydia, gave him a shot of penicillin and started him on an antiviral, then sent him home.

But his condition worsened - he developed rectal bleeding and pain, fever, chills, drenching sweats, and "new tender swelling in the groin," according to the Journal report. An ulcer, painless at least, developed on his penis. And "new scattered vesicular lesions appeared on the arms and legs."

Nine days after his initial visit to the first hospital, he went to Mass. General's infectious-disease clinic, where doctors took his history - which included a trip to "an urban area of southeastern Canada" during which "he had had sex with male partners without the use of barrier protection." They also tested him for various STIs, including HIV, even though he was taking PrEP drugs, started him on antibacterial and antiviral drugs, then also sent him home.

Two days later, though, his condition had become more painful and doctors admitted him to the hospital.

With the drugs not working, the doctors tried to figure out exactly what he had. First they ran down all the sexually-transmitted bacterial and viral diseases known to circulate in North America that can cause some of the symptoms he had, along with some easily spread diseases, such as chickenpox.

The thing in his case, though: Each of the diseases they considered could cause some of his symptoms, but none was known to cause all of them, the doctors wrote. Some of the symptoms of gonorrhea could include the sort of pustules he had, but not some of the ulcers. Molluscum contagiosum, caused by a poxvirus - a family that includes smallpox, chickenpox and, yes, monkeypox - can also cause the sort of postules he had, but not on the palms, and it doesn't cause the sort of swollen lymph nodes he had. Genital herpes could also explain some of his symptoms, but widespread rashes or lesions generally only occur in people with compromised immune systems, and his immune system seemed otherwise fine.

Chickenpox?

Could cutaneous contact result in anogenital disease followed by viremia and generalized rash? There have been rare reports of chickenpox occurring in a "diaper rash" distribution in children, but we could find no such reports in adults.

The patient and his doctors were not alone. Dr. Nesli Basgoz writes the patient told doctors that:

[H]e had been talking to two sexual contacts in Canada who had illnesses like his own. Their illnesses had also defied initial diagnosis and failed to resolve with empirical treatment.

The doctors considered whether he'd gotten really unlucky and gotten infected with several things at once. One by one, though, the doctors eliminated potential pathogens, not just because of the pattern of symptoms, but some after blood and DNA tests came back negative.

Then Basgoz had an "aha!" moment - and reached for her computer:

Very early one morning, I awoke thinking about the possibility of a poxvirus. A PubMed and general Internet search that included the terms "poxvirus," "outbreak," and "sexually transmitted infection" revealed a report that had been posted on the same day by public health authorities in the United Kingdom. It described four cases similar to this one, in which a diagnosis of monkeypox had been confirmed. It was at this point that I contacted the infection control unit at our hospital to report my concern that the patient may have monkeypox.

That UK report came out May 16. That day, the patient was moved to a single-bed room because he had possibly been exposed to Covid-19. Dr. Erica Shenoy wrote:

Personal protective equipment (PPE) — including a gown, gloves, eye protection, and an N95 respirator — had been instituted for all health care personnel entering the room. The same PPE is currently recommended when caring for patients with suspected or confirmed monkeypox in health care settings.

After conferring about the possibility of monkeypox, the doctors contacted the state epidemiologist, at the Department of Public Health, who recommended the patient be moved to an even more secure environment, in one of the hospital's ten "airborne infection isolation rooms" meant to minimize the risk of spreading airborne pathogens by having a lower air pressure than the surrounding building, with special exhaust vents and staffed by medical professionals trained in dealing with highly contagious diseases. Mass. General is one of ten hospitals across the US that has these rooms in its role as a Regional Emerging Special Pathogen Treatment Center.

Doctors sent samples from the patient's lesions and throat to both the state DPH lab in Jamaica Plain and the CDC in Atlanta. The state tests ruled out smallpox; the CDC test confirmed the presence of monkeypox and, in a stroke of good luck for the patient, a variant found in West Africa, which has proven far less fatal than another strain more common in Central Africa. To date this year, people infected with monkeypox away from Africa have tested positive for the West African strain.

While awaiting the results, the doctors started the process of contact tracing among both the patient's acquaintances and people at the two hospitals he had visited with whom he'd had contact before being put in isolation. All were monitored for symptoms for 21 days - none showed any signs of infection. Just in case, though, the hospital procured vaccines from the federal Strategic National Stockpile that can protect against monkeypox.

The doctors also alerted hospital administrators, who activated an "incident command system." Dr. Joshua Baugh said this included alerting hundreds of staff members who might be called into duty should the case not prove isolated:

At our hospital, the response to this case involved more than 30 hospital leaders participating in the hospital incident command system, as well as hundreds of frontline staff members.

The patient began to get better. His sores healed, the painful swelling subsided. On his ninth day at Mass. General, with his sores all having scabbed and fallen off, doctors concluded he was no longer infectious and released him.

On June 12, state health officials reported two more monkeypox cases in Boston, but said they had nothing to do with the Mass. General patient.

CDC Monkeypox page - information on the disease, how it spreads and its treatment.

Via Sibylla Bostoniensis.