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Monkeypox symptoms initially mistaken for jet lag, says PA treating cases

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"I would say COVID has pretty much prepared us for anything at this point," Maya Brooking told TODAY. But even with the pandemic, Brooking "was certainly not expecting" to be thinking about monkeypox on a daily basis.

A physician assistant at a OneMedical urgent care facility in San Francisco, Brooking diagnosed three confirmed monkeypox cases in the span of about two weeks. And, along with her local colleagues, she estimates they've seen about 10 cases now. Across the country, there are more than 390 confirmed cases, according to the latest data from the Centers for Disease Control and Prevention. California has counted 89 cases, the most of any state.

"I wish I could say that I was an infectious disease extraordinaire. But, truthfully, this has been very much a boots-on-the-ground kind of situation," she said, adding that diagnosing and treating patients with monkeypox has taken an incredible amount of teamwork and learning on the job.

Related: As monkeypox outbreak spreads, these pictures can help you identify symptoms

Monkeypox symptoms

The CDC has said some cases of monkeypox in the current outbreak look different from the classical presentation. In the past, symptoms have started with a fever, head and muscle aches and swollen lymph nodes followed by a telltale rash, which usually starts on the face or in the mouth and spreads to the extremities, especially the palms and soles of the feet. The lesions go through synchronized stages before scabbing over and forming a new layer of skin, at which point the person is no longer contagious.

But in the current monkeypox outbreak, some people have gotten the rash first followed by other symptoms, and others only ever got the rash. As of mid-June, every confirmed U.S. case had included a rash, but the rash has often appeared first around the anus or genitals. In some cases, the rash has stayed in one area or is scattered, rather than being spread out evenly, and never reaches the face or extremities. Lesions also been observed in different stages of healing at the same time.

When treating cases in the current outbreak, Brooking said the most consistent monkeypox symptoms that people have complained about are backache and headache.

"In most cases, before the lesions arrived, patients thought it was either jet lag or they just didn't sleep well the night before," she said. "The symptoms that I've seen thus far have been really quite mild."

In the current outbreak, CDC officials have also observed that lesions may start out looking like something more innocuous, maybe a pimple or blister. And that rings true for Brooking: "(If) they show up on the hands, a lot of people have been like, 'Oh, maybe I'm getting a wart. Or maybe this is just something I rubbed my hand against while I was out hiking.'"

But once the infection progresses, the lesions typically change in very noticeable ways. At first, "it really does not look like anything dramatic," Brooking explained. "But after a couple of days, it begins to develop this white center with a dimple in the middle that is larger than what you would anticipate from any of those other sources."

Then, when the lesions change or start showing up in other places, that's when people usually begin to realize that they're not just dealing with a pimple.

"In all of the cases that I've seen thus far, (patients) have had genital lesions, plus or minus lesions elsewhere on the body. And I haven't seen any cases where the lesions have had a head-to-toe distribution," Brooking said.

In fact, because the lesions are appearing in the genital area and may show up after a patient feels off for a few days, "the initial onset of symptoms can remind patients of a herpes outbreak," she added.

Providing treatment — and reassurance

To determine if someone with a suspected case of monkeypox actually has the disease, Brooking said she takes samples according to guidelines from the CDC and local health department.

"Thankfully, it's a pretty straightforward process of directly swabbing three different lesions," Brooking explained. "And then they have a courier come and take the samples to the lab."

Once diagnosed, the focus turns to keeping the patient isolated while they heal and offering prophylaxis (monkeypox vaccines) to those who may have been exposed, she said. There is an antiviral medication for monkeypox available, but so far Brooking hasn't seen it used.

Instead, to manage pain from the rash, Brooking advises patients to take over-the-counter pain medications like Tylenol and to cover the lesions to reduce the chances of spreading the virus. Other than that, she recommends basic advice for when you're not feeling well, including staying hydrated, getting good sleep, avoiding alcohol and eating well.

But the isolation can be hard for patients because it's so much longer than the usual five to 14 days for COVID-19, Brooking said. And it can be worrisome to be diagnosed with a virus that's spreading in a way that isn't typically seen in the U.S. So, on top of caring for patients' medical concerns, Brooking also finds herself providing a fair amount of reassurance and education.

"There's a lot of anxiety surrounding the unknowns and who else might have been exposed," Brooking said. Many times, "the photos (of monkeypox) you find online are of the worst possible cases. So there's a lot of catastrophizing."

Be "mindful" that this is circulating, Brooking said

People's past experiences with COVID-19 precautions are a "double-edged sword" she said. That familiarity with contact tracing and isolation guidelines from the pandemic is a useful frame of reference, but it's important to remember that monkeypox — while concerning in its own way — simply is not the coronavirus.

"(Monkeypox) is serious. It's something that we're really trying to contain and treat and provide prophylaxis for," Brooking said. "But it's really reassuring to patients to know that we're not looking at a scenario as grave and intense as COVID was."

For now, she recommends that people be "mindful" of the symptoms of monkeypox and to get in touch with their doctor if they're concerned. Telehealth makes that easier than ever because, if you do have a suspected case of monkeypox, a virtual visit ahead of time can help alert the facility to take the necessary precautions before you show up in person, Brooking said.

Related: How lessons from the HIV epidemic are shaping the public health response to monkeypox

Although early data suggest that men who have sex with men make up a high number of monkeypox cases in the current outbreak, the virus can affect people of all genders and sexual orientations, and any close contacts of someone with monkeypox are at risk.

"This just happens to be the demographic experiencing it," Brooking said. "We want all people to be thinking about this potential diagnosis ... (and) be thoughtful of their symptoms."

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