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In this episode of “Lab Medicine Rounds,” Justin Kreuter, M.D., sits down with Matt Binnicker, Ph.D., director of Clinical Virology and vice chair of practice in the Department of Laboratory Medicine and Pathology at Mayo Clinic, to discuss the laboratory medicine perspective of Monkeypox.
A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
(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)
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