Mireille was like any other teenage girl growing up – very conscious about her looks and very inquisitive about boys. As she was getting ready for her first day back at school, she couldn’t help but notice some raised pimple-like growths on her arms she brushed off as the usual pubertal blemish.
Expertly concealing this with her long sleeved school uniform, she simply dismissed it as a “fever blister.”
Like what her grandmother used to say, a “fever blister” was some kind of skin eruption appearing soon after a bout of fever. Incidentally the week before she had suffered one of the worst episodes of fever she had experienced. Accompanied by a terrible headache, chills and sweating, the fever was worsened by muscle, back and joint pains and some nausea.
She even had episodes of vomiting after forcing herself to eat. Her mother brought her to the local government hospital where she was diagnosed with malaria and given a three day course of antimalarial tablets with antipyretics. After the treatment, the symptoms subsided except that she continued to have some swollen glands on her neck as reminder of the previous weeks’ febrile episode.
The second day after the skin lesions appeared, she noticed the tell-tale pockmarks had spread to her hands and a few on the neck. This annoyed her considerably as she did not want to be teased by her peers. On the third day she decided to stay home telling everyone she was having a relapse from the “malaria” she had the previous week. Although she was not as tired and spent as she was the past week, she was still feeling exhausted and sleepy.
After a lengthy nap, she woke up later in the day to see with horror that most of her skin in the arms, legs and face was dotted with all sorts of raised lesions – tiny and vesicular. This was definitely not the usual teenage hormonal blemish! She thought this was definitely witchcraft! Could the hex have been from a friend who she knew also fancied a boy she dallied over? Or could it be the jealous neighbor who looked down on her family with disdain?
Things took a turn for the worse when the following day, her siblings were starting to become febrile, weak and very lethargic. Two sisters were reporting diarrhea and nausea and the youngest was having strange breathing patterns and started complaining of cough and flu. Over the next few days her three other siblings started developing similar skin lesions.
Beyond Skin Deep
With nowhere else to go, Mireille’s frantic mother and grandmother brought all the children to a treatment facility operated by Medecins Sans Frontiers (MSF – popularly known as Doctors Without Borders).
The grandmother was especially scared because she remembered such lesions usually meant death or disfigurement. As a young girl, she recalled a time when almost everyone in the village who had these lesions ended up dying. Those that survived were scarred for life and those who were not affected had to leave or risk contamination.
At the MSF treatment facility the doctors reassured the mother and grandmother that it was not a case of smallpox – a disease long eradicated. They explained what was happening to the family was likely to be a case of monkeypox, a viral zoonotic disease caused by the monkeypox virus (MPV) which is naturally found in certain primates and rodents and can infect humans after close contact or exposure.
The febrile episodes Mireille had the week before getting the lesions was not malaria but a prodromal phase or invasion period lasting a few days to less than a week. The family was also told the actual duration of the disease can be as short as two weeks but usually could reach up to a month with the cutaneous lesions lasting for as long as two to three weeks after the initial fever.
Like its deadly cousin, smallpox, monkeypox also presents with a prodrome of flu-like symptoms with skin lesions erupting a few days after onset of the initial symptoms. The rash, initially maculo-papular would later become pustule-like or vesicular in morphology and characteristically spreads to the extremities, face and neck. In more severe forms of the illness, the rash can also be found in the mucous membranes, palms, soles, trunk and genitalia.
If the lesions get to the eyes, corneal ulceration can occur. In fatal cases, it results in neurologic (encephalitis), respiratory (dyspnea) or hematologic (coagulation) complications or even multiorgan failure. Unlike smallpox, monkeypox presents with lymphadenopathy prominent in the head and neck area. Its case fatality rate based on various reports is anywhere between 0-33% versus smallpox which has a kill rate of as high as 30-90%. Post-convalescent morbidity in monkeypox is less severe than smallpox which causes severe scarring.
At the treatment center, the siblings were isolated and only the older more senior staff who had been vaccinated for smallpox attended to the siblings. Apparently previous smallpox vaccination confers some protection against monkey pox but even this can wane over time. Literature states that persons vaccinated for smallpox may still get monkey pox albeit a more benign illness with shorter duration.
Concerns of exposure from the other healthcare staff who had not been vaccinated for smallpox was raised. Weren’t they at high risk of contracting the illness? And weren’t they supposed to be given prophylactic smallpox vaccination?
Incidentally, the Centers for Disease Control (CDC) and World Health Organization (WHO) do not recommend pre-exposure inoculations unless such medical personnel are to be involved directly in active field investigations for monkeypox or are to perform necropsies of such cases. In any case, it was imperative the healthcare staff practice strict hand washing and enforce hygiene and sanitation protocols to avoid contamination.
This meant routine and prompt disinfection preferably using high level disinfectants such as 0.5% sodium hypochlorite solutions (bleach).
to be continued…
– Dr. Luc Victor, Medical Observer