Monkeypox: A Laboratory Medicine Perspective

(inspiring music) - This is Lab Medicine Rounds, a curated podcast for physicians, laboratory professionals and students. I'm your host, Justin Kreuter, the bow tie bandit of blood, a transfusion medicine pathologist at Mayo Clinic. Today, we're rounding with Dr. Matt Binnicker, the Director of Clinical Virology and Vice-Chair of Practice in the Department of Laboratory Medicine and Pathology at Mayo Clinic.

Given the rise in monkeypox cases, Dr. Binnicker is here to discuss the laboratory medicine perspective of this virus with us. Thank you for joining us today, Dr. Binnicker. - Hey, Dr. Kreuter, glad to be here again. - Hey, would you kinda start us off by giving us kind of an overview

of this latest outbreak of monkeypox and maybe also if you could kind of contrast that against COVID 19? 'Cause I think that's the other thing that a lot of us kinda have still in our minds a little bit. - Yeah. Happy to. So we've been living with COVID-19 now for 30 months, it's hard to believe. And in 2022, if someone would've asked me whether I'd believe that we'd be dealing with a monkeypox outbreak, I probably would've laughed.

But here we are, 2022 and certainly enough, there is a global outbreak of monkeypox virus. This is a disease that historically has mainly been confined to the continent of Africa. There have been a few outbreaks of this disease in other parts of the world, but very limited, low numbers of individuals impacted. But here this year with this outbreak, we now have over 50,000 confirmed cases worldwide. Here in the U.S., we have over 20,000 confirmed cases.

So a significant outbreak, definitely the largest monkeypox outbreak in recorded history. This disease is different from COVID-19 though. Monkeypox is spread primarily through direct skin-to-skin contact of an uninfected individual with an infected individual. In many cases during this latest outbreak are due to sexual transmission, not all but many.

The disease can also be spread through coming into contact with contaminated objects, like a contaminated piece of clothing or a bedspread or a towel that an infected individual has used and then not cleaned. That's accounting for relatively small number of cases. The disease is different in that it causes mainly a initially a viral prodrome, so a person might have a fever, body aches, and then several days later, they can develop a rash that can be highly varied in presentation.

In comparison to COVID-19, COVID is of course spread through the respiratory route through coughing, sneezing, breathing and mainly causes our respiratory illness. And because it's our respiratory disease, COVID-19 has of course infected hundreds of millions rather than tens of thousands. - It's interesting. So when you say 30 months like that, it really kinda strikes me a bit about living with COVID, but I hear you with monkeypox. It does sound like there's quite a bit of contrast

and you also certainly have my attention with this being the largest outbreak of monkeypox in recorded history. What do you think that this means then for our hospital laboratories? - Sure. Well, fortunately, monkeypox has been around for decades and so the CDC and other public health agencies have been aware of this and there's even been some tests that have been developed to help detect individuals who have monkeypox virus infection.

It's not something that clinical labs and hospital labs have ever performed before but the CDC did have a FDA approved test. And our laboratory at Mayo Clinic was identified as one of five reference laboratories in the country who the CDC partnered with to begin testing for monkeypox. So there is more clinical reference labs performing monkeypox testing currently than there was four months ago, but for most hospital clinical labs they're not performing testing.

They're sending their tests out to one of these reference labs or to their state public health laboratory. Now, the FDA has issued a requirement now that anyone who's going to be doing testing or developing a test for monkeypox needs to go through that emergency use authorization process. So that does open a door for commercial manufacturers to develop their own tests.

So I expect that here in the next two, three months, there will be tests that are authorized by the FDA for monkeypox and that will provide hospital labs, clinical labs the opportunity to purchase those tests and begin to test on their own, rather than sending samples out. That's gonna be important because sooner or later, most hospitals or clinics will interact with a patient with monkeypox, and so having that testing locally is important for patient care.

- Yeah, thanks for, so that kinda dives into my next question of kind of how as laboratory medicine professionals,

how can we really provide the greatest value to our clinical colleagues, to our patients? And it kind of sounds like, yeah, right now it really is a sendoff to a reference lab sort of situation. But that you're highlighting that in the future, this might be something that's brought in-house. Could you kinda unpack on how can laboratory medicine professionals really kinda bring value to our clinical colleagues and our patients? - For sure.

So with monkeypox infection, it is not a diagnosis that most clinicians can make based on how the patient presents alone. It's really a three-pronged diagnosis. One is good, detailed exposure history. Have they come in contact with someone with a dermal rash? Have they had unprotected sex with the new sexual partner? So getting those types of details. Two, does the individual who's presenting have rash-like illness? Have they had a viral prodrome illness preceding the development of that rash?

And then third and finally, getting that laboratory confirmation test to prove that it is monkeypox. So laboratory professionals play a key role in this process because without the testing, really difficult, probably almost impossible to confirm that someone has monkeypox virus infection. And it can present similarly to other diseases, herpes simplex virus, varicella-zoster virus even some non-infectious causes of dermal rashes can appear like monkeypox rashes in some cases.

So the lab testing that lab professionals perform is really what our providers need to confirm that someone has monkeypox virus infection to make sure that they isolate, don't transmit the disease further. There is some therapy that can be given and as well as post-exposure vaccination to monkeypox. So it is really critical that that lab testing can be performed to confirm the infection.

- Wow. So yeah, I really hear you about this being a team diagnosis which strikes home kind of the heart of this podcast about these critical conversations

connecting lab medicine and the clinical practice. And that three prong, you gotta work through that differential because otherwise your treatment is really gonna depend on what that diagnosis is for bringing value to the patient, for helping our clinical colleagues out. For us in the laboratory, now pardon my ignorance, but I know we sometimes do culture a virus and look at viruses.

Is it the case that that sort of testing that some of us may have in our laboratories, that's not specific enough, it looks like a couple other viruses, and that's why we have other tests that we're using? - Yeah, so I'm glad you brought up viral culture. It's a test that very few labs in the country still do because it takes quite a while for most viruses to grow in culture. And as you mentioned, it's not entirely specific.

So you may get observations on viral culture that may look like a viral infection, but it may not necessarily tell you exactly which virus is growing. Monkeypox will grow pretty readily in eukaryotic cell lines for labs that are still doing viral culture. It will grow on average in two or three days in several eukaryotic cell lines.

The problem is that recovery of monkeypox virus in the lab if it's not done in the right bio safety level precautions, it actually poses a pretty significant safety risk to lab personnel. Because we don't want to do any procedures that could aerosolize the sample because the risk for infection and our lab staff

is quite high with this virus. So we don't want samples being submitted to us for viral culture, instead, we really want those samples sent in for a molecular test, specifically PCR testing. - I gotcha. (chuckles) So earlier you had mentioned about the door being opened by the FDA for commercial vendors to develop tests for monkeypox.

And it kind of makes me wonder, is it kind of in that way, do you think that monkeypox would be similar to COVID-19 where we have kinda home test kits for the virus? - I think it's possible that maybe over the next six months, there might be some tests that are developed and authorized by the FDA that allow for point-of-care testing. I've already talked with several companies who are are working on products that are done outside the traditional clinical laboratory setting.

The difference I think, with COVID-19 and monkeypox is that with COVID 19, we've heard a lot about asymptomatic screening, so getting a nasal swab and trying to figure out if you're infected, but don't have symptoms. That probably isn't going to turn out to be as much of an issue with monkeypox because the preferred sample type for monkeypox is the rash, the lesion.

And there's some ongoing studies right now, trying to determine whether people who are infected with monkeypox, we can actually pick up the virus in the nose, in the throat before they develop symptoms. We'll wait and see how those data turn out.

I don't think it'll be as higher rate of positive results in asymptomatic individuals with monkeypox as we've seen with COVID-19, but there still will be interest in non-traditional testing, like point of care testing, as more people prefer privacy of collection and testing for monkeypox. - It's so cool. One of the commonalities that myself as sort of this insider outsider to the microbiology world is this evolving science of practice that we have.

And we saw it with COVID-19 and in real time how our knowledge develops and the response kind of based on public health principles, et cetera. And then now we're seeing this again with monkeypox as this evolves that clinical practice, how much science is at the forefront. And I hope for our listeners, physicians in practice develop this appreciation for the laboratory and how it is supporting the practice for the students.

I hope this is really kinda opening your eyes to this professional pathway. Like Dr. Binnicker has taken to be a microbiologist and for our kind of general audience, just to be more aware. So thank you for rounding with us Dr. Binnicker. - Hey, it's always good to talk with you, Dr. Kreuter, and I hope once we get through monkeypox that we can take a break from the infectious disease outbreak stuff. (Dr. Kreuter laughs) - Roger that. (laughs) To our listeners, thank you for joining us today.

We invite you to share your thoughts and suggestions by email. Please direct any suggestions to mcleducation@mayo.edu. If you've enjoyed Lab Medicine Rounds podcast, please follow or subscribe. And until our next rounds together, we encourage you to continue to connect lab medicine and the clinical practice through insightful conversations.