How a Boston doctor diagnosed the first monkeypox case in the United States

What happened next would challenge the team’s diagnostic skills and test two decades of preparation for the spread of new and exotic diseases around the world, such as COVID-19.

Baghouz, associate chief of the general and clinical director of the Division of Infectious Diseases, met the patient on his admission day, May 12.

She was upset that a dose of penicillin and an antiviral pill had failed to relieve his symptoms when he was on an outpatient basis. What could he have?

Baghouz explains that infectious disease specialists are actually generalists in the sense that they must understand the whole body and think broadly about what can go wrong. Infection can infect any organ and can take many forms – viruses, bacteria, fungi, parasites. Complicating matters further, the immune system can act in ways that mimic infection.

“Detective work really starts with listening very carefully to what people are saying and letting them tell their stories,” Basgus said.

These stories include the many ways a patient may have been exposed to an infectious agent. Is their dog licking their face? Do they eat raw seafood? Where did they travel to?

Now, this baffled new patient tells her that he traveled to Canada and quickly became ill upon his return. He stated that he had sex with men.

His illness had many of the characteristics of sexually transmitted diseases, and they were the biggest suspects. But the team had to consider other possibilities. Blood and skin sampling, and Basgoz testing for common viral infections, including chickenpox and other herpes viruses. It was considered an allergic reaction or an immune disorder – but this disease was progressing like an infection.

Tests continued to come back negative. The team of doctors, nurses, interns and microbiologists put their heads together. They’ve rerun the tests that were done, just to be sure. They gave the patient versions of the medications he had taken on an outpatient basis by intravenous infusion, hoping they would be more effective in this way. They weren’t.

All most likely hypotheses were omitted. What else could it be?

Basgoz contacted the Boston Public Health Commission and the state’s Department of Public Health to see if they had reports of similar illnesses. they did not.

Meanwhile, the patient was not getting worse. But he wasn’t getting better.

After a few days, Baghouz noticed a tangible change. The patient’s rash consists of fluid-filled blisters on parts of his body, including his scalp, palms, and soles. But now some of these blisters had a dent in the middle known as a navel (because the blister looks like a navel). The rash looked like smallpox. Basgus had never seen smallpox before, but she had become acquainted with it through her training.

However, the patient could not have had smallpox, because the virus had been eliminated from the planet. And he wasn’t nearly as sick as a smallpox patient.

Know Basgos There have been associated smallpox viruses – but these endemic to Africa. They have rarely been seen in the United States – and only in people who have traveled to Africa or had contact with infected animals imported from Africa. This guy did nothing.

The doctor woke up very early the next morning, May 17, thinking about the patient. She went to her computer and began researching smallpox viruses around the world.

I soon came across a warning issued by the UK the day before, describing four new cases of monkeypox, a virus found mainly in Central and West African countries. Health authorities in Britain were concerned that the infected men had not traveled to Africa, indicating undetected local transmission. They were identified as gay, bisexual, or men who have sex with men.

That’s when a rare disease appeared on the diagnostic radar. It was one of those “aha” moments, said Basgus.

At around 5am I emailed Dr Erica Shinoy, Associate Head of the Infection Control Unit, asking her to read and contact the UK report. The two met before six and within two hours were on the phone with state health officials: Dr. Catherine Brown, a state epidemiologist; Lawrence Madoff, MD, medical director for the Office of Infectious Diseases and Laboratory Sciences; Dr.. Laboratory officials and others in the Public Health Department.

This process – sharing disease information internationally, quick access to public health authorities locally, and openness to the potential for unfamiliar diseases – results from preparations that began when a new disease emerged, severe acute respiratory syndrome (SARS), which spread from China to four countries in 2002, Shinui said. These preparations accelerated when the Ebola outbreak in West Africa raised concerns (but little disease) in the United States in 2014, and took effect with the arrival of SARS-Cov-2, the virus that causes COVID-19, in 2020.

These systems “would have been in place if COVID-19 had not occurred,” Shinui said. “But COVID is asking for these networks and responses to be strengthened.”

By the time monkeypox reached Divine Liturgy this month, the system was up and running.

A sample of the patient’s blisters was sent to state laboratories for examination.

Meanwhile, the patient was transferred to the hospital’s Regional Treatment Center for Special Emerging Pathogens, one of 10 similar facilities across the country supported by the US Department of Health and Human Services. There, negative air pressure prevents any germs from escaping, and the staff is specially trained and equipped to avoid infection.

By late Tuesday, May 17, government labs had results: The patient had contracted a class of viruses that can include monkeypox. More tests will be needed at the CDC to narrow the results, and by the following afternoon, the CDC had confirmed monkeypox — the first case in the United States in this year’s outbreak.

“The state and the CDC have been incredibly responsive and the work has been done incredibly quickly,” Basgus said. “This was a very big success story.”

Since then, more cases of monkeypox have been identified in the United States, for a total of 12 as of late Saturday, as well as about 300 confirmed and suspected cases in 19 other countries, often involving gay men and people who have not travelled. to Africa. .

The recent outbreaks outside of Africa happen to occur in networks of men who have sex with men, but “no community is more biologically at risk than any other,” a statement from the American Infectious Diseases Association said.

Unlike COVID-19, monkeypox does not spread easily. Transmission occurs through contact with body fluids, respiratory droplets, monkeypox sores, or objects such as bedding or clothing contaminated with the virus.

Most people recover on their own after two to four weeks. The strain that has infected a Massachusetts man tends to be mild.

Indeed, it has gradually improved. When he turned out to be improving and no longer contagious on May 20, he was discharged from hospital.


Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter Tweet embed.

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