Key points
- Clinicians should conduct a thorough patient history, including sexual history, to assess possible exposure to mpox.
- Consider mpox when determining the cause of a diffuse or localized rash.
- All sexually active adults and adolescents in whom mpox is suspected should be evaluated for HIV and other STIs.
- Provide mpox patients with supportive care and pain control early in the illness.
Evaluating patients with suspected mpox
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 2022-2023 global outbreak. It is critical that clinicians take a detailed sexual history for any patient with suspected mpox.
Clinicians should perform a complete physical 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.
If mpox is suspected
Prevention
Managing patients exposed to mpox
Mpox vaccine can be given as post-exposure prophylaxis (PEP) both to people with known or presumed exposure to mpox virus. PEP can also be given to people with certain risk factors and recent experiences that might make them more likely to have been exposed to mpox. As PEP, vaccine should be given as soon as possible, ideally within four days of exposure; administration 4 to 14 days after exposure may still provide some protection against mpox and should be offered.
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
Based on available data from the 2022-2023 outbreak, CDC also recommends vaccinating additional populations with risk factors for exposure to mpox virus. Disproportionately affected populations should remain the focus of the current vaccination efforts. Mpox vaccination should be offered to people with the highest potential for exposure to mpox.
To be most effective, mpox vaccination should be included as part of broader prevention activities and sexual health care. Such efforts should have health equity principles as a foundation and include strategies such as allowing individuals to self-attest vaccine eligibility (i.e., providing mpox vaccination without requiring individuals to specify which criterion they meet), community outreach, holding vaccination events on-site in locations where groups of people disproportionately impacted by mpox may convene, education efforts, and communication about behavioral strategies to minimize risk.
Mpox vaccination strategies are likely to be most effective when designed and implemented in partnership with communities and groups that are disproportionately affected.
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 another 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 HIV/STI 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 ongoing clade II mpox 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 other STIs including syphilis, gonorrhea, and chlamydia in every sexually active adult and adolescent in whom mpox is suspected or confirmed.
Test for HIV in every sexually active adult and adolescent in whom mpox is suspected or confirmed 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.
Patient management
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.
Treatment should be considered for use in people who have severe disease or involvement of anatomic areas that 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.
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.