1
00:00:00,119 --> 00:00:02,952
(inspiring music)

2
00:00:05,760 --> 00:00:07,410
- This is Lab Medicine Rounds,

3
00:00:07,410 --> 00:00:10,800
a curated podcast for physicians,
laboratory professionals

4
00:00:10,800 --> 00:00:11,790
and students.

5
00:00:11,790 --> 00:00:14,970
I'm your host, Justin Kreuter,
the bow tie bandit of blood,

6
00:00:14,970 --> 00:00:18,060
a transfusion medicine
pathologist at Mayo Clinic.

7
00:00:18,060 --> 00:00:20,327
Today, we're rounding
with Dr. Matt Binnicker,

8
00:00:20,327 --> 00:00:24,170
the Director of Clinical Virology
and Vice-Chair of Practice

9
00:00:24,170 --> 00:00:26,670
in the Department of Laboratory
Medicine and Pathology

10
00:00:26,670 --> 00:00:28,350
at Mayo Clinic.

11
00:00:28,350 --> 00:00:31,530
Given the rise in monkeypox cases,

12
00:00:31,530 --> 00:00:33,195
Dr. Binnicker is here to discuss

13
00:00:33,195 --> 00:00:37,350
the laboratory medicine
perspective of this virus with us.

14
00:00:37,350 --> 00:00:39,690
Thank you for joining
us today, Dr. Binnicker.

15
00:00:39,690 --> 00:00:42,150
- Hey, Dr. Kreuter, glad to be here again.

16
00:00:42,150 --> 00:00:43,740
- Hey, would you kinda start us off

17
00:00:43,740 --> 00:00:45,595
by giving us kind of an overview

18
00:00:45,595 --> 00:00:50,490
of this latest outbreak of monkeypox

19
00:00:50,490 --> 00:00:53,190
and maybe also if you
could kind of contrast that

20
00:00:53,190 --> 00:00:54,077
against COVID 19?

21
00:00:54,077 --> 00:00:55,770
'Cause I think that's the other thing

22
00:00:55,770 --> 00:00:59,640
that a lot of us kinda have
still in our minds a little bit.

23
00:00:59,640 --> 00:01:01,170
- Yeah. Happy to.

24
00:01:01,170 --> 00:01:04,560
So we've been living with
COVID-19 now for 30 months,

25
00:01:04,560 --> 00:01:05,853
it's hard to believe.

26
00:01:06,690 --> 00:01:10,230
And in 2022, if someone would've asked me

27
00:01:10,230 --> 00:01:11,063
whether I'd believe

28
00:01:11,063 --> 00:01:13,650
that we'd be dealing with
a monkeypox outbreak,

29
00:01:13,650 --> 00:01:15,030
I probably would've laughed.

30
00:01:15,030 --> 00:01:18,390
But here we are, 2022
and certainly enough,

31
00:01:18,390 --> 00:01:22,010
there is a global outbreak
of monkeypox virus.

32
00:01:22,010 --> 00:01:26,670
This is a disease that historically
has mainly been confined

33
00:01:26,670 --> 00:01:27,780
to the continent of Africa.

34
00:01:27,780 --> 00:01:30,150
There have been a few
outbreaks of this disease

35
00:01:30,150 --> 00:01:31,800
in other parts of the world,

36
00:01:31,800 --> 00:01:36,800
but very limited, low numbers
of individuals impacted.

37
00:01:36,960 --> 00:01:39,090
But here this year with this outbreak,

38
00:01:39,090 --> 00:01:43,170
we now have over 50,000
confirmed cases worldwide.

39
00:01:43,170 --> 00:01:47,250
Here in the U.S., we have
over 20,000 confirmed cases.

40
00:01:47,250 --> 00:01:49,650
So a significant outbreak,

41
00:01:49,650 --> 00:01:52,320
definitely the largest monkeypox outbreak

42
00:01:52,320 --> 00:01:54,210
in recorded history.

43
00:01:54,210 --> 00:01:57,720
This disease is different
from COVID-19 though.

44
00:01:57,720 --> 00:02:00,180
Monkeypox is spread primarily

45
00:02:00,180 --> 00:02:04,967
through direct skin-to-skin contact

46
00:02:06,210 --> 00:02:09,900
of an uninfected individual
with an infected individual.

47
00:02:09,900 --> 00:02:12,510
In many cases during this latest outbreak

48
00:02:12,510 --> 00:02:16,230
are due to sexual
transmission, not all but many.

49
00:02:16,230 --> 00:02:19,950
The disease can also be spread
through coming into contact

50
00:02:19,950 --> 00:02:22,560
with contaminated objects,

51
00:02:22,560 --> 00:02:27,210
like a contaminated piece
of clothing or a bedspread

52
00:02:27,210 --> 00:02:31,350
or a towel that an infected
individual has used

53
00:02:31,350 --> 00:02:32,733
and then not cleaned.

54
00:02:33,570 --> 00:02:37,927
That's accounting for relatively
small number of cases.

55
00:02:37,927 --> 00:02:39,720
The disease is different in that

56
00:02:39,720 --> 00:02:43,170
it causes mainly a
initially a viral prodrome,

57
00:02:43,170 --> 00:02:46,260
so a person might have
a fever, body aches,

58
00:02:46,260 --> 00:02:47,550
and then several days later,

59
00:02:47,550 --> 00:02:50,820
they can develop a rash
that can be highly varied

60
00:02:50,820 --> 00:02:52,023
in presentation.

61
00:02:53,640 --> 00:02:55,620
In comparison to COVID-19,

62
00:02:55,620 --> 00:02:57,960
COVID is of course spread
through the respiratory route

63
00:02:57,960 --> 00:03:00,540
through coughing, sneezing, breathing

64
00:03:00,540 --> 00:03:03,180
and mainly causes our respiratory illness.

65
00:03:03,180 --> 00:03:04,860
And because it's our respiratory disease,

66
00:03:04,860 --> 00:03:08,910
COVID-19 has of course
infected hundreds of millions

67
00:03:08,910 --> 00:03:10,983
rather than tens of thousands.

68
00:03:12,930 --> 00:03:13,770
- It's interesting.

69
00:03:13,770 --> 00:03:18,360
So when you say 30 months like that,

70
00:03:18,360 --> 00:03:22,260
it really kinda strikes me a
bit about living with COVID,

71
00:03:22,260 --> 00:03:24,390
but I hear you with monkeypox.

72
00:03:24,390 --> 00:03:28,530
It does sound like there's
quite a bit of contrast

73
00:03:28,530 --> 00:03:30,660
and you also certainly have my attention

74
00:03:30,660 --> 00:03:35,660
with this being the largest
outbreak of monkeypox

75
00:03:35,910 --> 00:03:38,310
in recorded history.

76
00:03:38,310 --> 00:03:41,820
What do you think that this means then

77
00:03:41,820 --> 00:03:44,853
for our hospital laboratories?

78
00:03:45,750 --> 00:03:46,583
- Sure.

79
00:03:46,583 --> 00:03:51,583
Well, fortunately, monkeypox
has been around for decades

80
00:03:51,600 --> 00:03:56,040
and so the CDC and other
public health agencies

81
00:03:56,040 --> 00:03:59,130
have been aware of this and
there's even been some tests

82
00:03:59,130 --> 00:04:02,490
that have been developed
to help detect individuals

83
00:04:02,490 --> 00:04:04,200
who have monkeypox virus infection.

84
00:04:04,200 --> 00:04:07,260
It's not something that
clinical labs and hospital labs

85
00:04:07,260 --> 00:04:09,450
have ever performed before

86
00:04:09,450 --> 00:04:14,430
but the CDC did have a FDA approved test.

87
00:04:14,430 --> 00:04:17,820
And our laboratory at Mayo Clinic

88
00:04:17,820 --> 00:04:20,970
was identified as one of
five reference laboratories

89
00:04:20,970 --> 00:04:24,000
in the country who the CDC partnered with

90
00:04:24,000 --> 00:04:25,980
to begin testing for monkeypox.

91
00:04:25,980 --> 00:04:30,300
So there is more clinical reference labs

92
00:04:30,300 --> 00:04:32,430
performing monkeypox testing currently

93
00:04:32,430 --> 00:04:35,040
than there was four months ago,

94
00:04:35,040 --> 00:04:37,470
but for most hospital clinical labs

95
00:04:37,470 --> 00:04:39,210
they're not performing testing.

96
00:04:39,210 --> 00:04:40,675
They're sending their tests out

97
00:04:40,675 --> 00:04:42,714
to one of these reference labs

98
00:04:42,714 --> 00:04:46,050
or to their state public
health laboratory.

99
00:04:46,050 --> 00:04:50,400
Now, the FDA has issued a requirement now

100
00:04:50,400 --> 00:04:52,980
that anyone who's going
to be doing testing

101
00:04:52,980 --> 00:04:55,500
or developing a test for
monkeypox needs to go

102
00:04:55,500 --> 00:04:58,890
through that emergency
use authorization process.

103
00:04:58,890 --> 00:05:01,080
So that does open a door

104
00:05:01,080 --> 00:05:04,800
for commercial manufacturers
to develop their own tests.

105
00:05:04,800 --> 00:05:07,920
So I expect that here in
the next two, three months,

106
00:05:07,920 --> 00:05:10,590
there will be tests that are authorized

107
00:05:10,590 --> 00:05:13,470
by the FDA for monkeypox

108
00:05:13,470 --> 00:05:17,700
and that will provide
hospital labs, clinical labs

109
00:05:17,700 --> 00:05:20,040
the opportunity to purchase those tests

110
00:05:20,040 --> 00:05:22,260
and begin to test on their own,

111
00:05:22,260 --> 00:05:24,390
rather than sending samples out.

112
00:05:24,390 --> 00:05:28,440
That's gonna be important
because sooner or later,

113
00:05:28,440 --> 00:05:30,630
most hospitals or clinics will interact

114
00:05:30,630 --> 00:05:32,070
with a patient with monkeypox,

115
00:05:32,070 --> 00:05:35,173
and so having that testing locally

116
00:05:35,173 --> 00:05:36,993
is important for patient care.

117
00:05:37,830 --> 00:05:38,670
- Yeah, thanks for,

118
00:05:38,670 --> 00:05:42,750
so that kinda dives into
my next question of kind of

119
00:05:42,750 --> 00:05:46,020
how as laboratory medicine professionals,

120
00:05:46,020 --> 00:05:49,450
how can we really provide
the greatest value

121
00:05:50,730 --> 00:05:53,790
to our clinical colleagues,
to our patients?

122
00:05:53,790 --> 00:05:54,690
And it kind of sounds like,

123
00:05:54,690 --> 00:05:59,460
yeah, right now it really is a sendoff

124
00:05:59,460 --> 00:06:03,690
to a reference lab sort of situation.

125
00:06:03,690 --> 00:06:06,060
But that you're highlighting
that in the future,

126
00:06:06,060 --> 00:06:09,690
this might be something
that's brought in-house.

127
00:06:09,690 --> 00:06:10,523
Could you kinda unpack

128
00:06:10,523 --> 00:06:15,523
on how can laboratory
medicine professionals

129
00:06:15,750 --> 00:06:17,070
really kinda bring value

130
00:06:17,070 --> 00:06:20,220
to our clinical colleagues
and our patients?

131
00:06:20,220 --> 00:06:21,053
- For sure.

132
00:06:21,053 --> 00:06:23,283
So with monkeypox infection,

133
00:06:24,270 --> 00:06:28,200
it is not a diagnosis that
most clinicians can make

134
00:06:28,200 --> 00:06:31,380
based on how the patient presents alone.

135
00:06:31,380 --> 00:06:34,860
It's really a three-pronged diagnosis.

136
00:06:34,860 --> 00:06:37,920
One is good, detailed exposure history.

137
00:06:37,920 --> 00:06:42,060
Have they come in contact with
someone with a dermal rash?

138
00:06:42,060 --> 00:06:46,470
Have they had unprotected sex
with the new sexual partner?

139
00:06:46,470 --> 00:06:48,903
So getting those types of details.

140
00:06:50,160 --> 00:06:52,530
Two, does the individual who's presenting

141
00:06:52,530 --> 00:06:54,990
have rash-like illness?

142
00:06:54,990 --> 00:06:57,480
Have they had a viral prodrome illness

143
00:06:57,480 --> 00:06:59,682
preceding the development of that rash?

144
00:06:59,682 --> 00:07:01,290
And then third and finally,

145
00:07:01,290 --> 00:07:03,840
getting that laboratory confirmation test

146
00:07:03,840 --> 00:07:06,570
to prove that it is monkeypox.

147
00:07:06,570 --> 00:07:11,220
So laboratory professionals
play a key role in this process

148
00:07:11,220 --> 00:07:14,130
because without the
testing, really difficult,

149
00:07:14,130 --> 00:07:16,170
probably almost impossible to confirm

150
00:07:16,170 --> 00:07:19,110
that someone has
monkeypox virus infection.

151
00:07:19,110 --> 00:07:24,110
And it can present
similarly to other diseases,

152
00:07:24,390 --> 00:07:28,800
herpes simplex virus,
varicella-zoster virus

153
00:07:28,800 --> 00:07:32,850
even some non-infectious
causes of dermal rashes

154
00:07:32,850 --> 00:07:37,650
can appear like monkeypox
rashes in some cases.

155
00:07:37,650 --> 00:07:41,280
So the lab testing that
lab professionals perform

156
00:07:41,280 --> 00:07:44,940
is really what our
providers need to confirm

157
00:07:44,940 --> 00:07:47,730
that someone has monkeypox virus infection

158
00:07:47,730 --> 00:07:50,823
to make sure that they isolate,

159
00:07:50,823 --> 00:07:53,784
don't transmit the disease further.

160
00:07:53,784 --> 00:07:57,060
There is some therapy that can be given

161
00:07:57,060 --> 00:08:02,060
and as well as post-exposure
vaccination to monkeypox.

162
00:08:02,070 --> 00:08:04,410
So it is really critical
that that lab testing

163
00:08:04,410 --> 00:08:06,750
can be performed to confirm the infection.

164
00:08:06,750 --> 00:08:08,880
- Wow. So yeah, I really hear you

165
00:08:08,880 --> 00:08:12,090
about this being a team diagnosis

166
00:08:12,090 --> 00:08:14,970
which strikes home kind of
the heart of this podcast

167
00:08:14,970 --> 00:08:18,120
about these critical conversations

168
00:08:18,120 --> 00:08:20,460
connecting lab medicine
and the clinical practice.

169
00:08:20,460 --> 00:08:21,817
And that three prong,

170
00:08:21,817 --> 00:08:23,910
you gotta work through that differential

171
00:08:23,910 --> 00:08:28,140
because otherwise your
treatment is really gonna depend

172
00:08:28,140 --> 00:08:32,220
on what that diagnosis is for
bringing value to the patient,

173
00:08:32,220 --> 00:08:35,280
for helping our clinical colleagues out.

174
00:08:35,280 --> 00:08:39,540
For us in the laboratory,
now pardon my ignorance,

175
00:08:39,540 --> 00:08:43,020
but I know we sometimes do culture a virus

176
00:08:43,020 --> 00:08:45,240
and look at viruses.

177
00:08:45,240 --> 00:08:48,908
Is it the case that that sort of testing

178
00:08:48,908 --> 00:08:52,290
that some of us may have
in our laboratories,

179
00:08:52,290 --> 00:08:55,920
that's not specific enough,

180
00:08:55,920 --> 00:08:57,810
it looks like a couple other viruses,

181
00:08:57,810 --> 00:09:02,810
and that's why we have other
tests that we're using?

182
00:09:04,080 --> 00:09:06,630
- Yeah, so I'm glad you
brought up viral culture.

183
00:09:06,630 --> 00:09:10,200
It's a test that very few
labs in the country still do

184
00:09:10,200 --> 00:09:12,000
because it takes quite a while

185
00:09:12,000 --> 00:09:15,060
for most viruses to grow in culture.

186
00:09:15,060 --> 00:09:17,640
And as you mentioned, it's
not entirely specific.

187
00:09:17,640 --> 00:09:21,750
So you may get observations
on viral culture

188
00:09:21,750 --> 00:09:23,670
that may look like a viral infection,

189
00:09:23,670 --> 00:09:25,650
but it may not necessarily
tell you exactly

190
00:09:25,650 --> 00:09:27,210
which virus is growing.

191
00:09:27,210 --> 00:09:32,210
Monkeypox will grow pretty
readily in eukaryotic cell lines

192
00:09:32,370 --> 00:09:35,190
for labs that are still
doing viral culture.

193
00:09:35,190 --> 00:09:38,070
It will grow on average
in two or three days

194
00:09:38,070 --> 00:09:42,390
in several eukaryotic cell lines.

195
00:09:42,390 --> 00:09:47,340
The problem is that recovery
of monkeypox virus in the lab

196
00:09:47,340 --> 00:09:50,340
if it's not done in the right
bio safety level precautions,

197
00:09:50,340 --> 00:09:52,890
it actually poses a pretty
significant safety risk

198
00:09:52,890 --> 00:09:54,780
to lab personnel.

199
00:09:54,780 --> 00:09:57,570
Because we don't want to do any procedures

200
00:09:57,570 --> 00:09:59,261
that could aerosolize the sample

201
00:09:59,261 --> 00:10:03,090
because the risk for
infection and our lab staff

202
00:10:03,090 --> 00:10:05,070
is quite high with this virus.

203
00:10:05,070 --> 00:10:07,770
So we don't want samples
being submitted to us

204
00:10:07,770 --> 00:10:09,210
for viral culture,

205
00:10:09,210 --> 00:10:12,210
instead, we really want
those samples sent in

206
00:10:12,210 --> 00:10:15,625
for a molecular test,
specifically PCR testing.

207
00:10:15,625 --> 00:10:17,760
- I gotcha. (chuckles)

208
00:10:17,760 --> 00:10:22,760
So earlier you had mentioned
about the door being opened

209
00:10:24,090 --> 00:10:27,030
by the FDA for commercial vendors

210
00:10:27,030 --> 00:10:30,207
to develop tests for monkeypox.

211
00:10:30,207 --> 00:10:35,207
And it kind of makes me wonder,
is it kind of in that way,

212
00:10:35,250 --> 00:10:38,940
do you think that monkeypox
would be similar to COVID-19

213
00:10:38,940 --> 00:10:43,940
where we have kinda home
test kits for the virus?

214
00:10:44,550 --> 00:10:48,870
- I think it's possible that
maybe over the next six months,

215
00:10:48,870 --> 00:10:52,920
there might be some tests that
are developed and authorized

216
00:10:52,920 --> 00:10:56,730
by the FDA that allow for
point-of-care testing.

217
00:10:56,730 --> 00:10:59,190
I've already talked with several companies

218
00:10:59,190 --> 00:11:03,000
who are are working on
products that are done

219
00:11:03,000 --> 00:11:06,183
outside the traditional
clinical laboratory setting.

220
00:11:07,260 --> 00:11:11,280
The difference I think,
with COVID-19 and monkeypox

221
00:11:11,280 --> 00:11:13,410
is that with COVID 19,

222
00:11:13,410 --> 00:11:16,320
we've heard a lot about
asymptomatic screening,

223
00:11:16,320 --> 00:11:19,680
so getting a nasal swab
and trying to figure out

224
00:11:19,680 --> 00:11:21,963
if you're infected, but
don't have symptoms.

225
00:11:22,800 --> 00:11:25,440
That probably isn't going to turn out

226
00:11:25,440 --> 00:11:28,170
to be as much of an issue with monkeypox

227
00:11:28,170 --> 00:11:33,030
because the preferred
sample type for monkeypox

228
00:11:33,030 --> 00:11:35,370
is the rash, the lesion.

229
00:11:35,370 --> 00:11:37,800
And there's some ongoing
studies right now,

230
00:11:37,800 --> 00:11:39,360
trying to determine whether people

231
00:11:39,360 --> 00:11:41,460
who are infected with monkeypox,

232
00:11:41,460 --> 00:11:44,850
we can actually pick up the
virus in the nose, in the throat

233
00:11:44,850 --> 00:11:47,220
before they develop symptoms.

234
00:11:47,220 --> 00:11:50,490
We'll wait and see how
those data turn out.

235
00:11:50,490 --> 00:11:54,030
I don't think it'll be as
higher rate of positive results

236
00:11:54,030 --> 00:11:56,610
in asymptomatic individuals with monkeypox

237
00:11:56,610 --> 00:11:58,650
as we've seen with COVID-19,

238
00:11:58,650 --> 00:12:02,340
but there still will be interest
in non-traditional testing,

239
00:12:02,340 --> 00:12:04,170
like point of care testing,

240
00:12:04,170 --> 00:12:07,140
as more people prefer
privacy of collection

241
00:12:07,140 --> 00:12:08,673
and testing for monkeypox.

242
00:12:09,540 --> 00:12:10,429
- It's so cool.

243
00:12:10,429 --> 00:12:13,650
One of the commonalities that myself

244
00:12:13,650 --> 00:12:18,650
as sort of this insider outsider
to the microbiology world

245
00:12:18,720 --> 00:12:23,720
is this evolving science
of practice that we have.

246
00:12:24,480 --> 00:12:28,230
And we saw it with
COVID-19 and in real time

247
00:12:28,230 --> 00:12:31,530
how our knowledge
develops and the response

248
00:12:31,530 --> 00:12:34,847
kind of based on public
health principles, et cetera.

249
00:12:34,847 --> 00:12:38,370
And then now we're seeing
this again with monkeypox

250
00:12:38,370 --> 00:12:41,640
as this evolves that clinical practice,

251
00:12:41,640 --> 00:12:44,250
how much science is at the forefront.

252
00:12:44,250 --> 00:12:49,097
And I hope for our listeners,
physicians in practice

253
00:12:49,097 --> 00:12:52,800
develop this appreciation
for the laboratory

254
00:12:52,800 --> 00:12:55,170
and how it is supporting the
practice for the students.

255
00:12:55,170 --> 00:12:57,720
I hope this is really
kinda opening your eyes

256
00:12:57,720 --> 00:13:00,180
to this professional pathway.

257
00:13:00,180 --> 00:13:04,226
Like Dr. Binnicker has
taken to be a microbiologist

258
00:13:04,226 --> 00:13:09,226
and for our kind of general
audience, just to be more aware.

259
00:13:10,320 --> 00:13:13,770
So thank you for rounding
with us Dr. Binnicker.

260
00:13:13,770 --> 00:13:16,980
- Hey, it's always good to
talk with you, Dr. Kreuter,

261
00:13:16,980 --> 00:13:19,140
and I hope once we get through monkeypox

262
00:13:19,140 --> 00:13:20,010
that we can take a break

263
00:13:20,010 --> 00:13:21,576
from the infectious
disease outbreak stuff.

264
00:13:21,576 --> 00:13:23,296
(Dr. Kreuter laughs)

265
00:13:23,296 --> 00:13:26,040
- Roger that. (laughs)

266
00:13:26,040 --> 00:13:29,040
To our listeners, thank
you for joining us today.

267
00:13:29,040 --> 00:13:30,570
We invite you to share your thoughts

268
00:13:30,570 --> 00:13:32,014
and suggestions by email.

269
00:13:32,014 --> 00:13:37,014
Please direct any suggestions
to mcleducation@mayo.edu.

270
00:13:37,470 --> 00:13:39,630
If you've enjoyed Lab
Medicine Rounds podcast,

271
00:13:39,630 --> 00:13:41,160
please follow or subscribe.

272
00:13:41,160 --> 00:13:42,750
And until our next rounds together,

273
00:13:42,750 --> 00:13:45,870
we encourage you to continue
to connect lab medicine

274
00:13:45,870 --> 00:13:49,293
and the clinical practice
through insightful conversations.