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As the still-rare monkeypox crops up around the world, including
a San Francisco case now among five in California, people on the
alert for the symptoms may not always see the typical patterns
and blisters.

The rash is there, but experts say it may be subtle, even
unnoticed, and it doesn�t always start on the face. As well, the
more recent disease may present with or without the flu-like
symptoms of traditional monkeypox.

�The rash is similar in some senses, and different in others, to
what we know about �textbook� monkeypox,� UCSF infectious
disease expert Peter Chin-Hong said Sunday. �The major
difference in this current outbreak is that the rash appears to
start in the genital area and the anus rather than the face or
trunk. From the genitals, it can move to the arms and palms of
the hands, and sometimes the face, including the mouth.�

Humans usually contract monkeypox through a bite or scratch of
an infected animal. But because this latest global outbreak is
so widespread, human-to-human contact is suspected. Monkeypox
can be spread through lesions, bodily fluids, respiratory
droplets and intimate or sexual contact, but it is not a
sexually-transmitted disease.

Symptoms usually begin with a fever, headache, swollen lymph
nodes, muscle aches, chills and fatigue. Monkeypox is milder
than its cousin smallpox, and does not include swollen lymph
nodes, according to the CDC.

The characteristic rash develops in 1-3 days in the form of pus-
filled blisters that in the past have begun on the face and then
moved to other parts of the body. But in many recent cases the
blisters start in different areas and are localized to one
region.

Many patients have a rash isolated to just the genital or anal
area, said Chin-Hong, with �fewer lesions than in textbook
cases.�

�The type or nature of the rash is the same: it starts off as a
red spot which evolves to fluid or pus-filled blisters which can
then evolve into ulcers then scab off,� he wrote in an email to
The Chronicle. �They can be extremely painful, but not always.�

Another difference from �textbook� monkeypox is that flu-like
symptoms do not always show up after the rash develops, although
in some cases they do. Therefore monkeypox may be mistaken for
other illnesses.

�The current presentation of the rash and blisters is more
subtle than in previous outbreaks so infected individuals may
not even notice they have them,� Chin-Hong said. �Early on it
may look like a boil or a staph infection, later on it may look
like herpes or syphilis ulcers. When it scabs off, it may even
resemble how chicken pox scabs off.�

But if the blisters start in the genital area and move to the
face or another part of the body, it is �highly suggestive of
monkeypox especially if there has been sexual contact for this
particular outbreak,� Chin-Hong added.

More than 30 countries are reported to have logged recent
monkeypox outbreaks, with the majority in Europe. The U.S.
Centers for Disease Control and Prevention has reported 25 cases
as of June 3 across the country. Officials announced Friday that
a San Francisco man who traveled to an area with a monkeypox
outbreak likely has the disease.

While many of the cases so far have been seen in gay, bisexual
other men who have sex with men, the World Health Organization
stressed that monkeypox is not limited to those individuals.
Anyone who has been in close contact with an infected person is
as at risk. Public health officials say it�s important not to
demonize any group.

The CDC says the illness lasts 2 to 4 weeks. Many infected
people have a �mild, self-limiting disease course.� Monkeypox
has mainly afflicted central and western African countries,
where the first human case was reported in 1970 in the
Democratic Republic of Congo. The disease there has become
endemic, with a death rate as high as 10%.

Kellie Hwang is a San Francisco Chronicle staff writer. Email:
kellie.hwang@sfchronicle.com Twitter: @KellieHwang

https://www.sfchronicle.com/bayarea/article/Here-is-what-to-look-
out-for-as-monkeypox-cases-17221272.php