Health

How Boston doctors diagnosed the first US case of monkeypox

It was an “aha moment.”

By Ross Cristantiello

May 30, 2022

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When Dr. Nesli Basgoz, Associate Chief and Clinical Director of the Infectious Disease Division at Massachusetts General Hospital, met her new patient on May 12, she was mystified. The man in front of her was an enigma, or at least his medical condition was. 

Basgoz and a team of infectious disease specialists had inherited this patient from Dr. Benjamin Davis, who was concerned about the man’s worsening condition and, unusually, a lack of diagnosis. 

When the man had first entered Davis’ care, The Boston Globe reported, nothing appeared particularly out of the ordinary. His symptoms — fever, sweating, swollen lymph nodes, and a rash — could be caused by many different infections. But Davis’ typical tests did not provide any answers, and standard medications didn’t alleviate the patient’s symptoms.  

So the challenge of not only helping the man, but diagnosing the root cause of his symptoms, fell to Basgoz and her colleagues. 

Particularly troubling to Basgoz was the fact that both a shot of penicillin and antiviral pills did not alleviate any symptoms in the man while he was still an outpatient, the Globe reported. 

There were many possible answers to this puzzle. Infections can affect any organ in the body and can be caused by viruses, fungi, bacteria, or parasites. Sometimes the body’s immune system even mimics the infection. Infectious disease specialists must understand the entire human body and think generally about what could be causing symptoms, Basgoz told the Globe.

“The detective work really starts with listening very carefully to what people say and letting them tell their stories,” Basgoz said.

The stories of this patient revealed that he has sex with men, and had quickly gotten sick after traveling to Canada. 

These clues were an important starting point for Basgoz, but more testing needed to be done quickly. Blood and skin samples were used to rule out common viral infections like chickenpox or other herpes viruses. An immune disorder or an allergic reaction could have caused these symptoms, but the way the illness progressed pointed towards an infection. Tests came back negative and were re-done. The same drugs given to the man before he was admitted were administered intravenously this time, but they were not effective.  

The Boston Public Health Commission and the state Department of Public Health both told Basgoz that they did not have reports of similar illnesses. 

The breakthrough for MGH physicians came a few days later, when the patient’s symptoms changed in a major way. Up until that point, the man’s rash had fluid-filled blisters. These occurred on his scalp, palms, and soles, the Globe reported.  But now, Basgoz observed a change to those blisters. They developed a dent in the center known as an umbilication, pointing in a direct line towards smallpox. 

Basgoz recognized the smallpox-like symptoms from her training, but the disease was officially declared eradicated in 1980. On top of that, the man in MGH would have been in much worse condition had he somehow contracted smallpox. 

But the trail towards the truth was getting clearer. Basgoz knew of monkeypox and other pox viruses that are still endemic to Africa, but these had rarely been seen in the U.S. On top of that, only people that had traveled to Africa or that had come into contact with infected African animals were known to catch these viruses. 

Basgoz told the Globe she woke up early on the morning of May 17 and immediately began researching pox viruses. All of a sudden, she found the biggest clue yet: an advisory issued by the United Kingdom describing four new cases of monkeypox. It was issued on May 16. The infected men in the U.K. had also not traveled to Africa, and they all identified as gay, bisexual, or as men who have sex with men.

It was an “aha moment,” Basgoz said. 

By 5 a.m., she was firing off an email to Dr. Erica Shenoy, associate chief of the Infection Control Unit. Shenoy read the UK advisory, and circled back to Basgoz. A few hours later, the two joined a conference call with state health officials. This included Dr. Catherine Brown, state epidemiologist; Dr. Lawrence Madoff, medical director of the Bureau of Infectious Disease and Laboratory Sciences; laboratory officials, and others from the Department of Public Health.

When severe acute respiratory syndrome, the first SARS, spread from China to four other countries in 2002, the groundwork was laid for 2022’s global network of sharing disease information, Shenoy told the Globe. The Ebola outbreak in 2014 led officials to better perfect the system, and COVID-19’s rise crystallized it even further.  

“[This system] would have been in place had COVID-19 not happened,” Shenoy said. “But COVID required strengthening of these networks and responses.”

The patient was immediately moved to MGH’s Regional Emerging Special Pathogens Treatment Center. There are 10 similar facilities around the country, where negative air pressure prevents germs from escaping and staff is specially equipped to control the spread of disease. At the same time, a sample from the man’s blisters was sent to a state laboratory for testing. 

Those results came back quickly. Late on May 17, Basgoz and her team learned that the patient was infected with a category of viruses that could include monkeypox. One more round of tests at the CDC confirmed that the patient had monkeypox. 

“The state and the CDC were incredibly responsive and the work was done with astonishing rapidity,” Basgoz said. “This was a very big success story.”

Monkeypox was first discovered in 1958 when two colonies of monkeys kept for research were diagnosed. The first human case popped up in 1970, and it has largely been contained to central and western Africa. 

An exception occurred in 2003, when Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin reported 47 confirmed and probable cases, according to the CDC. Those patients caught the virus from pet prairie dogs, which were infected after being housed near imported small mammals from Ghana.

As of Monday, the CDC has confirmed 14 cases of monkeypox throughout the country. They are being reported from California, Colorado, Florida, Massachusetts, New York, Utah, Virginia, and Washington. About 300 confirmed and suspected cases have been reported in 19 other countries. Those patients also identify as men who have sex with men and have not traveled to Africa. 

Although the disease is spreading in a network of men who have sex with men, “no one community is biologically more at risk than any other,” said a statement from the Infectious Diseases Society of America.

Transmission of monkeypox generally occurs through contact with body fluids, either directly or through contaminated clothing or linens. Transmission could also occur through large respiratory droplets, but prolonged face-to-face contact would be necessary. 

Recovery normally takes two to four weeks, and the strain detected in Massachusetts appears to be mild, the Globe reported. Basgoz’s patient left the hospital on May 20, after his condition improved and he was no longer considered infectious.