Monkeypox Fatalities Reported as Cases Escalate

Liz Scherer

August 02, 2022

Four fatalities from the escalating global monkeypox outbreak have been confirmed since last week: two in Spain, one in India, and one in Brazil, according to public health authorities in those countries.

Should US clinicians start worrying? Not yet, according to public health experts.

While monkeypox is generally self-limiting and nonthreatening in otherwise healthy people, Catherine Smallwood, a senior emergency official at WHO Europe, acknowledged in a statement to the Associated Press that monkeypox "can cause severe complications."

Still, "the notification of deaths due to monkeypox does not change our assessment of the outbreak in Europe," she said; in most cases, the disease is self-limiting and does not require treatment.

As of July 27, that assessment was based on European Center for Disease Control and WHO Regional Europe surveillance, which reported 12,689 confirmed cases across 37 countries and European regions.

Cases also continue to spread throughout the majority of the United States and its territories. There were 5189 CDC-confirmed cases as of July 29. But US experts appear not to be unduly alarmed by the European and Southeast Asian fatalities.

Dr Amesh Adalja

"I think that when you have tens of thousands of cases worldwide, that there are going to be some cases that are fatal," Amesh Adalja, MD, a senior scholar at the Johns Hopkins University Center for Health Security, told Medscape Medical News.

"But this doesn't seem to be very common outside the endemic countries...and the hospitalization numbers are not very alarming," he said.

Brazilian and Spanish authorities have shared limited information about the case fatalities (eg, two people were young, one had encephalitis, and one had lymphoma and a weakened immune system). Adalja said that the reports are missing certain key pieces of data.

Factors linked to fatalities include underlying medical conditions and immunosuppression. Some manifestations have led to death (eg, a brain infection or superinfection of a skin lesion), and some patients have died despite receiving antiviral therapy.

"These are important for clinicians to know to be able to understand what is happening in this new situation," Adalja said.

US clinicians should be on the lookout for red flags, he said.

"The most feared complication of monkeypox is central nervous system involvement, anything that could indicate encephalitis — clouding of sensorium, mental status changes, change in cognition — those should alert the clinician that the virus might be causing a brain infection," Adalja explained.

Other red flags include intractable or unremitting pain (especially in relation to lesions and similar to proctitis), unremitting fever leading to dehydration in the presence of comorbidities that commonly lower physiologic reserves, and being severely immunocompromised. In addition, swollen lymph nodes are a concern, especially those that compromise the airways, something that happened during the 2003 US monkeypox outbreak, Adalja noted.

In addition to those red flags, it behooves clinicians and other healthcare providers in the US to take a page from the WHO playbook by focusing on the most dominant mode of transmission, which currently is skin-to-skin contact during sexual encounters, as well as groups at highest risk for becoming infected.

"We have to be clear that this virus has gotten itself into a sexual social network and has been able to exploit that network, where individuals who have close contact with each other are in close contact with multiple individuals in short periods of time," said Adalja.

"It isn't specific to this group, and historically, this has not been something that has been seen in this group," he added.

It's time to take a breath before heading into a COVID-like panic.

"In the United States, this is a disease that does not usually produce severe cases," said Adalja, "so I think that the number of fatalities will be low."

Adalja has disclosed no relevant financial relationships.

Liz Scherer is an independent journalist specializing in infectious and emerging diseases, cannabinoid therapeutics, neurology, oncology, and women's health.

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