Mpox (Monkeypox) Clinical Pathway — Emergency Department, Outpatient Specialty Care and Primary Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Patient Education

Provider Resources

Related Pathway
- Cellulitis/Abscess, ED and Inpatient
- Sexually Transmitted Infections (STI) in Adolescents, ED

Evaluation of Child or Adolescent
with Concern for Mpox

Exposure Screen
- Close contact (sexual, household) with person with suspected or confirmed case in preceding 21 days
- and
- Rash, fever/rash

ED Triage/Clinician Intake
Expedite to room, close door as able
Standard Precautions

Suspected case: exposure + rash
or new onset characteristic rash
- Exposure, Epidemiologic Criteria
  - Sexual contact (e.g., oral, anal, vaginal) in the preceding 21 days
  - Household, sexual, or close physical contact w/suspected or confirmed case
  - Travel to high-risk location in the preceding 21 days
- Rash
  - Solely anogenital or may appear on other areas like the hands, feet, chest, face, or mouth
  - Appears as pustules, papules,
    or vesicles
  - Evolves into scabs
  - May be painful or pruritic
- Prodrome
  - Fever, chills, headache, malaise, myalgia, lymphadenopathy
- CDC – Signs and Symptoms

History
Assess:
- Symptoms, prodrome, rash
- Exposure, Epidemiologic Criteria
  - Sexual contact (e.g., oral, anal, vaginal) in the preceding 21 days
  - Household, sexual, or close physical contact with suspected or confirmed case
  - Travel History
- Risk Factors for severe disease

Physical
- Gloves should be used for skin exam for all patients with rash
- Don expanded precautions for physical exam, specimen collection
- Perform thorough skin and mucosal (e.g., anal, vaginal, oral) examination for the characteristic rash visual diagnosis
Use of Chaperones During Sensitive Area Physical Examinations

Exposure, Asymptomatic with
Normal Physical Exam
Standard Precautions

Exposure + Prodrome without Rash
Standard Precautions

Rash Present (+/- Prodrome)
Expanded Precautions

Indications for Vaccination

Disposition
- Patient Counseling
  - Discuss anticipatory symptom monitoring for rash, isolation
- Indications for Vaccination

Diagnostic Testing
- Orthopoxvirus Testing
  - Specimen Collection, Ordering
- Additional Testing, as indicated
  - HSV, syphilis, GC/CT, VZV, enterovirus, HIV
- Review Differential Diagnosis
- Rash Visual Diagnosis

Discharge
- Patient Counseling
- Discharge Instructions — English
- Discharge Instructions — Spanish
- Isolation not indicated

Discharge
- Patient Counseling
- Discharge Instructions — English
- Discharge Instructions — Spanish
- Isolation not indicated
- Follow-up

Positive Test
- Patients and families should be informed of positive results
- Immediately and provided Isolation Guidance

Patient Counseling
- Isolation Guidance
Indications for Vaccination
- Patients, Close Contacts

Reporting Guidance

Consult and Admission Considerations
- ID Consult Considerations
- Admission Considerations
  - Negative pressure room
  - Expanded Precautions
  - ED Referral Considerations

Posted: August 2022
Revised: November 2024

Authors:
- S. Wood MD;
- C. Kerman, MD;
- S. Jelinek, MD;
- J. Lavelle, MD;
- M. Russo, MD;
- L. Karel, PharmD;
- H. Yoon, MPH;
- S. Townsend, MS-HQS;
- M. Langer, MD;
- E. Hayes, MD;
- K. Cohn, MD

Evidence

Related Links

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Emergency Department, Outpatient Specialty Care, and Primary CareClinical Pathway for the Evaluation and Management of Mpox (Monkeypox)

Evidence

Related Links

Emergency Department, Outpatient Specialty Care, and Primary Care
Clinical Pathway for the Evaluation and Management of Mpox (Monkeypox)