Alaskapox: The beat goes on

By Warren R. Heymann, MD, FAAD
Feb. 21, 2024
Vol. 6, No. 8

I feel like Phil Connors (Bill Murray) from Groundhog Day caught in a time loop since 2020 — Biden-Trump, San Francisco 49ers-Kansas City Chiefs, mass shootings, COVID-19 variants du jour, and mPox spiking. Since it is a presidential election year, I will paraphrase Ronald Reagan — here we go again — introducing Alaskapox (AP).

Please note that there is minimal peer-reviewed literature about AP and most references provided are from the Alaska Department of Health and the lay press. This situation will change in short order.

Poxviridae is a family of large, double-stranded DNA viruses that infect a broad range of animal hosts. The Orthopoxvirus genus includes well-known pathogens for smallpox (variola), vaccinia, cowpox, and mPox (monkeypox). (1) Molluscum contagiosum belong to the Molluscipoxvirus genus. (2)

According to Gigante et al., “Since the eradication of smallpox, there have been increases in poxvirus infections and the emergence of several novel poxviruses that can infect humans and domestic animals. In 2015, a novel poxvirus was isolated from a resident of Alaska. Diagnostic testing and limited sequence analysis suggested this isolate was a member of the Orthopoxvirus (OPXV) genus but was highly diverged from currently known species, including Akhmeta virus. Here, we present the complete 210,797 bp genome sequence of the Alaska poxvirus isolate, containing 206 predicted open reading frames. Phylogenetic analysis of the conserved central region of the genome suggested the Alaska isolate shares a common ancestor with Old World OPXVs and is diverged from New World OPXVs. We propose this isolate as a member of a new OPXV species, Alaskapox virus (AKPV).” (1)

AKPV may have existed for much longer and that mild clinical disease was undiagnosed. “‘Six of the seven cases have been mild and self-limited, so the patient didn’t even need to get any supportive care from a health care provider,’ said Dr. Joe McLaughlin, state epidemiologist and chief of the Alaska Section of Epidemiology at the Alaska Department of Health.” (3)

With one exception, all patients lived in the Fairbanks North Star Borough; one person lived in the Kenai Peninsula Borough. AKPV primarily occurs in small mammals. The virus has been most commonly identified in red-backed voles and shrews, although domestic dogs and cats may play a role in spreading the virus. To date, no human-to-human transmission of AKPV has been reported. (4)

According to the Alaska Division of Public Health, “People with Alaskapox have had one or more skin lesions and other symptoms like swollen lymph nodes and joint or muscle pain. Several Alaskapox patients initially thought they had a spider or insect bite. Nearly all patients had mild illnesses that resolved on their own after a few weeks. There has been one patient with an immunocompromising condition that developed severe disease and died after prolonged illness.” (5) [The images I have seen mostly look like characteristic, umbilicated pustules that become necrotic. Many have surrounding erythema. One photograph suggests secondary infection with attendant lymphangitis.] The fatal case was an older man who was likely immunosuppressed from his cancer chemotherapy. (6) He also had slow wound healing, malnutrition, acute renal failure, and respiratory failure. (3) Although it is not clear how he contracted AP, it may have been linked to a stray cat that lived with him. The cat tested negative for the virus but it regularly hunted small mammals and frequently scratched the patient. (6)

Treatment of AP focuses on avoiding direct contact of skin lesions to prevent direct virus transmission. This is accomplished by bandaging wounds and not sharing bedding or linens that have come in contact with the lesions. (5) Antiviral and immune-globulin treatments have been prescribed (I am not sure which therapies — tecovirimat? Vaccinia immune globulin?) (3) Clinicians who suspect AP should contact the Alaska Section of Epidemiology (907-269-8000). (4)

Dr. McLaughlin said, “There’s no need for people outside of Alaska to be concerned. Those within Alaska should just be aware that it is an infection that they can acquire.” (3) I have been to “The Last Frontier” twice — on our honeymoon and for our twentieth anniversary. If vacationing now, I would not be anxious about acquiring AP (playing with voles and shrews is not my passion); I am concerned about the larger picture. Climate change has forced some animal species into new habitats, potentially increasing contact between humans and animals. Arctic temperatures are rising more than twice as rapidly as the rest of the world — this has increased the vole population. As global temperatures rise, so does the risk of importing other emerging infectious diseases throughout the United States. (7)

Point to Remember: Alaskapox is a newly recognized infectious disease due to an Orthopoxvirus likely transmitted by small mammals. Most cases are mild, but a fatal case has been reported in a presumably immunosuppressed host. As with other emerging infectious diseases, climate change may be at play. 

Our Expert’s Viewpoint

Misha Rosenbach, MD, FAAD
Professor of Dermatology at the Hospital of the University of Pennsylvania

I should no longer be surprised at Warren’s capacity to near-instantly consume news related to dermatology, digest it, and translate it into important information for our field. His commentary on Alaskapox is, at present, the authoritative piece and includes all that is known about this novel (rare, localized) entity.

I will note that Warren was probably first alerted to this story through the same way I was — an outstanding piece of local news highlighting the important work by the Alaska Department of Health. In the same week that this came out, I unfortunately saw two other pieces of relevant medical news — the first being an announcement that Spotify gave Joe Rogan a $250 million contract. Unfortunately, he continues to share medical misinformation on his podcast (which just this week hosted someone sharing falsehoods about HIV and AIDS). Secondly, the European CDC alerted that the WHO European region experienced over 21,000 hospitalizations for measles in 2023. (8) The importance of journalism, local news, and medical experts is absolutely critical to medicine and public health, while facing a tremendous challenge from misinformation, of which the anti-vax movement is at the forefront.

Over the past five years we have seen a range of public health responses to emerging threats, highlighting the need for evidence-based, scientifically led responses to health threats. The response to mpox nicely illustrates both ends of that spectrum. The rapid development and repurposing of vaccines, with a clear public health strategy targeted at high-risk populations, and innovative work to identify variable dosing strategies, helped lead to rapid vaccine uptake and a corresponding reduction in cases — in the U.S. and in Europe. Unfortunately, mpox continues to be a problem in Africa, where it had smoldered for years as a neglected disease until cases cropped up abroad. It is important that we remember that dermatology sits within the broader house of medicine, and that all of us live in an interconnected world.

I am excited that the AAD has recognized this by creating a new Emerging Diseases Task Force. This task force will build upon the important work that Dr. Esther Freeman and many others started, first with the onset of the COVID-19 pandemic (9), and then with the emergence of mpox (10), to attempt to assess potential emerging threats, gather critical information in a streamlined fashion, digest, and share that information with the entire medical community. With climate change already impacting the timing and geography of infectious diseases (such as tick-borne illnesses expanding their habitat and seasonality, vector-borne tropical illnesses such as leishmania and Zika occurring in the continental U.S., coccidiodomycosis spreading across the West as far north as Washington, among many others), our field needs to stay abreast of changing patterns of diseases and alert for new health threats. This also represents another opportunity for our field to highlight “SkinSerious” and partner dermatology with the broader house of medicine — including opportunities to expand on the work that our group did in collaboration with CDC in providing guidance for the management of skin lesions in severe mpox infections. (11) The work of Penn Dermatology’s alumnus Avrom Caplan in helping identify drug resistant tinea caused by Trichophyton indotineae is another example of dermatology partnering with CDC and alerting the country to a novel, emerging pathogen here in the U.S. (12)

Dermatologists play a critical role in diagnosing and treating skin disease, and it is essential that we all stay alert for new and changing patterns of emerging diseases, and do our part to support clear, evidence-based, scientifically guided communication and decision making to care for our patients and improve population-based health.

1. Gigante CM, Gao J, Tang S, McCollum AM, Wilkins K, Reynolds MG, Davidson W, McLaughlin J, Olson VA, Li Y. Genome of Alaskapox Virus, A Novel Orthopoxvirus Isolated from Alaska. Viruses. 2019 Aug 1;11(8):708. doi: 10.3390/v11080708. PMID: 31375015; PMCID: PMC6723315.

2. Efridi W, Lappin SL. Poxviruses. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558959/

3. Musa A. What to know about Alaskapox after official report first known fatal case. https://www.cnn.com/2024/02/13/health/alaskapox-virus-xpn/index.html

4. https://health.alaska.gov/dph/Epi/id/Pages/Alaskapox.aspx

5. https://health.alaska.gov/dph/Epi/id/SiteAssets/Pages/Alaskapox/Alaskapox-FAQ.pdf

6. https://www.cbsnews.com/news/alaska-man-dies-alaskapox-virus-fatality-stray-cat/

7. https://www.cdc.gov/ncezid/what-we-do/climate-change-and-infectious-diseases/index.html

8. European Centre for Disease Prevention and Control. Measles on the rise in the EU/EEA: considerations for public health response. 16 February 2024. Stockholm: ECDC; 2024.

9. Freeman EE, McMahon DE, Lipoff JB, et al. The spectrum of COVID-19-associated dermatologic manifestations: an international registry of 716 patients from 31 countries. JAAD 2020

10. Prasad S, Galvan Casas C, Strahan AG. A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak. J Am Acad Dermatol 2023;88(5):1066.

11. Rao AK, Schrodt CA, Minhaj FS, et al. Interim clinical treatment considerations for severe manifestations of Mpox – United States, February 2023. MMWR 2023;72(9):232-43.

12. Caplan AS, Chaturvedi S, Zhu Y, et al. Notes from the field: first reported US case of tinea caused by Trichophyton indotineae – New York City, December 2021-March 2023. MMWR 2023;72(19):536.