Monkeypox case in a California toddler is a reminder that viruses don’t discriminate

A 3-year-old boy visited a pediatric infectious diseases specialist in Long Beach in late June after suffering a fever, cough and a blistering rash. The rash looked unusual for hand, foot and mouth disease, a common infection in kids during the summer, but his parents had received a notice from the family’s preschool that they had an outbreak. 

The boy’s parents didn’t think the rash looked like hand, foot and mouth either — first, the bumps weren’t in any of those areas. Both parents are health care providers, and they knew about the recent surge in monkeypox cases. They talked to several doctors, including dermatologists, and they all reassured them that monkeypox wasn’t likely in kids.

The test for monkeypox at the Long Beach doctor’s office was negative. But because they were concerned, the boy’s parents took him to public health for testing at the end of July.

The boy, who I’ll call P. to protect his privacy as a minor, was positive for monkeypox.

John, the boy’s father, said the kids in the family fell ill before the parents, and he’s concerned that the presumed cases of hand, foot and mouth at his son’s preschool may actually be monkeypox.

“We got a call while we were on a cruise for our fifth anniversary that he had fever,” John said.

The couple returned from the cruise two days later, and then the whole family of six, including three children younger than 10, became ill with fever and rashes.

“The rash can be itchy, at times really painful like someone is sticking needles in them,” said John. To him, the family’s rashes never looked like the “big scary blisters” seen in some cases reported by the media.  

On July 23, the World Health Organization declared monkeypox a “public health emergency of international concern.” Monkeypox cases increased more than four-fold from about 4,000 cases in June to 14,000 cases across 71 countries by mid-July.  In the United States, cases surged to more than 6,300 by August 2, according to the Centers for Disease Control and Prevention (CDC).

Until now, human infections with monkeypox have primarily occurred in Central and West Africa, rarely causing outbreaks in other continents. But this changed in May, when a flurry of cases identified in Europe rapidly spread around the globe, including in the United States.

The initial cases have been predominantly among gay men, bisexual men and men who have sex with men (MSM). That pattern has led some public health officials to make comparisons with the early days of HIV/AIDS epidemic.

“The virus seems to be concentrated among MSM … but like HIV/AIDS before it, there is no way in the world it will remain isolated to that demographic,” said Dr. Mark Kline, physician and chief at Children’s Hospital of New Orleans and an internationally renowned HIV expert.

“Many of us are being lulled into the same sense of complacency that existed in the early days of HIV/AIDS. It (monkeypox) is not just a disease of gay men,” Kline said.

“It’s not like a virus discriminates,” he added.

P. and his family are a perfect illustration that anyone can catch the infection. P. has the third confirmed case in children in the U.S. and the second in California, as of August 2. Two additional children in Indiana were diagnosed in the past day, according to ABC news.

In the U.S., approximately 99% of monkeypox cases have been reported among MSM, but infections are being increasingly recognized among others.

Rashes due to other causes, such as typical summer viruses such as enterovirus, contact with plants like poison ivy or other allergic reactions, are common in children. Monkeypox is still rare in kids, and though uncomfortable, full recovery is the usual course. However, there are concerns about kids transmitting the virus to others, including people with weakened immune systems.

Kline is worried that doctors will assume the virus is only circulating among men who have sex with other men and miss cases in others. Without his parents’ persistence, P.’s diagnosis could’ve been missed.

“We’ve been dealing with this since June and finally got tested on July 28. That’s six weeks since it started,” said John, the father.

Social media is flush with posts from women and heterosexual men with monkeypox symptoms, including the characteristic rash, who could not get tested because they weren’t considered at risk by their health providers. For example, one Twitter user posted that a friend’s mother couldn’t get tested at a hospital in North Carolina because she wasn’t gay, despite her possible exposure as a massage therapist.

Initially, some public health agencies prioritized testing for high-risk groups, which they identified as gay and bisexual men, MSM, people with multiple sexual partners or international travelers. However, only testing those groups means only finding cases in those groups. In contrast, the CDC recommends testing for anyone with a suspected case of monkeypox, regardless of demographics.

Likewise, the United Nations, WHO, CDC and other public health officials have since issued statements that emphasize the virus can infect anyone.

Anti-viral treatments are available for monkeypox, and the infection is potentially preventable with vaccination.

Monkeypox vaccines remain in limited supply and the CDC recommends prioritization for vaccines to people who have been exposed or who may be more likely to get monkeypox. That includes those with a known exposure, people with multiple sexual partners in past two weeks and those with occupational risks, such as some health care workers and lab workers.

The virus was first identified in monkeys in a research lab in 1958, and is related to the smallpox virus. Cases of monkeypox can look similar to smallpox but it is generally milder, though cases can be severe, painful and, rarely, deadly. The virus is spread through close, intimate contact with an infected person, touching the rash, or contact with contaminated surfaces, clothing or other objects. It may also be spread by respiratory secretions amid prolonged exposure.

Kline said monkeypox is not a sexually transmitted infection in the classic sense but it is readily spread by sexual activity.

The virus can also cross the placenta barrier and infect the infant of a pregnant person. It can also spread from animals to people. In 2003, an outbreak occurred in the U.S. among prairie dogs and humans, which was linked to contact with imported exotic pets from Africa. The virus has reservoirs in small mammals in Africa.

Kline expressed concerns about the possibility of the monkeypox establishing a reservoir among domestic mammals in the U.S., though there isn’t evidence yet to determine how likely that may be.

He said scaling up availability and distribution of vaccines, including for the general population, is essential to stop the virus from spreading broadly.

“I would consider this a time for heightened awareness but certainly not panic,” said Kline.

John, P.’s father, wants journalists and the broader public to know that anyone can catch monkeypox. “It can happen to anybody. It doesn’t care about your age, your race or orientation. Just look at my kids.”

**

ChrisAnna Mink is a pediatrician and journalist based in Los Angeles.