Clinical Quick Reference

History and Physical Examination

Clinicians should conduct a thorough patient history to assess possible mpox exposures or epidemiologic risk factors. Mpox is usually transmitted through close, sustained physical contact and has been almost exclusively associated with sexual contact in the 2022 global outbreak. It is critical that clinicians take a detailed sexual history for any patient with suspected mpox.

Clinicians should perform a complete physician examination, including a thorough skin and mucosal (e.g., oral, genital, anal) examination for the characteristic vesiculo-pustular rash of mpox; this allows the clinician to detect lesions of which the patient may be unaware.

Mpox should be considered when a clinician is trying to determine the cause of a diffuse or localized rash. Other considerations include herpes simplex virus (HSV; genital herpes), syphilis, herpes zoster (shingles), disseminated varicella-zoster virus infection, molluscum contagiosum, scabies, lymphogranuloma venereum, allergic skin rashes, and drug eruptions.

Diagnostic Testing Based on Clinical Impression

Mpox Testing

Specimens should be obtained from lesions (including those inside the mouth, anus, or vagina), if accessible, and tested for mpox.

Other Sexually Transmitted Infection (STI) Testing

Evaluate any individual presenting with genital, anal, or perianal ulcers, proctitis syndrome, or diffuse rash for STIs per the 2021 CDC STI Treatment Guidelines. The diagnosis of an STI does not exclude mpox, as a concurrent infection may be present.

Anogenital ulcers

Specific evaluation of genital, anal, or perianal ulcers includes 1) syphilis serology tests, and, if available, darkfield examination of lesion exudate or tissue, or nucleic acid amplification test (NAAT); 2) NAAT or culture for genital herpes type 1 or 2; and 3) serologic testing for type-specific HSV antibody.

Proctitis

All persons with proctitis should be evaluated for herpes simplex (preferably by NAAT of rectal lesions), gonorrhea (NAAT or culture), chlamydia (NAAT), and syphilis (darkfield of lesion and serologic testing).

Diffuse rash

The differential diagnosis for patients presenting with diffuse rash can be broad and its evaluation in sexually active adults and adolescents should include diagnostic and treatment considerations for the following STIs: syphilis, HSV (genital herpes), molluscum contagiosum, disseminated gonococcal infection, and scabies.

Additional Considerations for Patients with Suspected or Confirmed Mpox

All sexually active adults and adolescents in whom mpox is suspected should be evaluated for HIV and other STIs, with appropriate care offered to those with positive test results. In the 2022 outbreak, HIV infection and other STIs have been highly prevalent among persons with mpox. Furthermore, people with HIV-associated immunocompromise are at risk for severe manifestations of mpox.

Test for HIV in every sexually active adult and adolescent in whom mpox is suspected if current HIV status is unknown.

Ensure those with HIV and with suspected or confirmed mpox are on effective antiretroviral therapy and linked to care to optimize immune function.

Discuss and facilitate access to HIV pre-exposure prophylaxis (PrEP) for those who are HIV negative and at risk for HIV.

Instruct patients with suspected mpox to follow isolation recommendations and avoid close contact with other people and with animals, including pets.

Treatment

Patients with mpox benefit from supportive care and pain control that is implemented early in the illness. Illness depends on a person’s immune response. Mpox can commonly cause severe pain and can affect vulnerable anatomic sites, including the genitals and oropharynx, which can lead to other complications.

Assess pain in all patients with mpox virus infection and recognize that substantial pain may exist from mucosal lesions not evident on physical exam. Topical and systemic strategies should be used to manage pain. Pain management strategies should be individualized and patient-centered, tailored to the needs and context of an individual patient.

For most patients with intact immune systems, supportive care and pain control may be enough. However, because prognosis depends on multiple factors, supportive care and pain control may not be enough for some patients (for example, those with weakened immune systems). In these cases, treatment should be considered.

Treatment should be considered for use in people who have severe disease or involvement of anatomic areas which might result in serious sequelae that include scarring or strictures. Treatment should also be considered for use in people who are at high risk for severe disease. For patients at high risk for progression to severe disease, treatment should be administered early in the course of illness along with supportive care and pain control.

While there are currently no treatments specifically approved for mpox, therapeutics developed for patients with smallpox have been deployed during the 2022 mpox outbreak.

Consider tecovirimat as first-line therapy for eligible patients with mpox. If you are a provider who intends to prescribe tecovirimat, consider first seeking access through enrollment in the AIDS Clinical Trials Group (ACTG) Study of Tecovirimat for Human Mpox Virus (STOMP) trial. For patients not eligible for the STOMP trial or who decline to participate, contact your local health department to receive tecovirimat through the CDC’s Expanded Access-IND.

Consider testing lesion swab specimens for tecovirimat resistance and plasma pharmacokinetic sample collection for any patient who, after completing 14 days of tecovirimat treatment, experiences persistent or newly emergent mpox lesions.

Additional medical countermeasures can be considered as additive or alternative therapy for treating mpox virus infections in certain situations. Decisions on whether and when to use these medical countermeasures must be made individually for each person and can depend on a variety of clinical and other parameters. CDC offers a clinical consultation service (email eocevent482@cdc.gov) or healthcare providers may contact the CDC Emergency Operations Center [EOC] at (770) 488-7100 where CDC can provide additional guidance to clinicians with patient management questions.

Clinical Considerations for Specific Patient Types

People with HIV and Other Immunocompromising Conditions

People with HIV-associated immunosuppression and people with HIV who are not virologically suppressed can be at increased risk of severe mpox.

People who are immunocompromised from other conditions or using immunosuppressive agents may be at increased risk of severe mpox.

The use of tecovirimat for treatment of mpox should be considered in people who are immunocompromised. Recognize that patients with severe immunocompromise may require longer courses of tecovirimat, as well as additional therapies, until their immune systems can effectively clear the virus.

People Who are Pregnant or Breastfeeding

Data regarding mpox virus infection in pregnancy are limited. It is unknown if pregnant people are more susceptible to mpox virus or if infection is more severe in pregnancy.

Mpox virus can be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth. It is unknown if mpox virus is present in breast milk; however, given that mpox virus is spread by close contact and neonatal mpox infection may be severe, breastfeeding should be delayed until criteria for discontinuing isolation have been met.

While most non-pregnant adults with an mpox virus infection experience mild illness and recover spontaneously, pregnant, recently pregnant, and breastfeeding people should be prioritized for medical treatment if needed. Following consultation with CDC, if treatment is indicated, tecovirimat should be considered the first-line antiviral for people who are pregnant, recently pregnant, or breastfeeding.

Children and Adolescents

Young children, children with eczema and other skin conditions, and children with immunocompromising conditions may be at increased risk of severe disease.

Treatment should be considered on a case-by-case basis for children and adolescents with suspected, probable, or confirmed mpox who are at risk of severe disease or who develop complications of mpox.

Counseling Message on Condoms

It is not known whether condoms prevent the transmission of mpox. If rashes are confined to the genitals or anus, condoms may help. However, since infectious respiratory secretions may be present, condoms alone are probably not enough to prevent mpox. Condoms are effective at preventing the transmission of some infections, such as chlamydia, gonorrhea, and HIV. The World Health Organization advises that people with mpox use condoms for 12 weeks after they recover until more is known about levels of the virus and potential infectivity in semen during the period that follows recovery.

Managing Patients Exposed to Mpox

People with exposure to someone with mpox are ideally vaccinated within four days [i.e., post-exposure prophylaxis (PEP)]. Vaccine can be considered between 4 and 14 days after exposure but may be less effective. Benefits may still outweigh risks when administering vaccine more than 14 days after exposure in some clinical situations.

Additionally, people with certain risk factors and experiences that increase their risk for recent exposure to mpox can be considered for vaccination (i.e., expanded post-exposure prophylaxis [PEP++]).

Persons exposed to mpox through sexual contact who are asymptomatic should also be tested for HIV and other sexually transmitted infections.

Discuss and facilitate access to HIV pre-exposure prophylaxis (PrEP) for people who are HIV negative and at risk for HIV.

Managing Patients at Increased Risk for Mpox Exposure

During the current outbreak, in jurisdictions where PEP and PEP++ are being implemented and local supply is available, mpox pre-exposure prophylaxis has been provided for individuals at increased risk for exposure to mpox.

To have the greatest impact on the current outbreak, jurisdictions implementing mpox pre-exposure prophylaxis should determine which populations to focus their efforts on based on potential for exposure to mpox, local epidemiology, population needs, and vaccine availability.