This week has offered two stark reminders that monkeypox infections can be more than skin-deep.

A person diagnosed with monkeypox died this week in Harris County, Texas, according to the Department of State Health Services.

That case could be the first monkeypox-related death in the US. The unidentified resident was described only as a “severely immunocompromised” adult. Local public health officials are working with the CDC to determine the role monkeypox may have had in contributing to the death.

“We know that this patient had monkeypox as a diagnosis. What we do not know for sure is that this patient passed away from monkeypox,” said Dr. Ericka Brown, a local authority from Harris County Public Health, during a news conference.

And in Portugal, doctors are reporting a “potential causal relationship” between monkeypox and a dangerous heart condition. A 31-year-old patient developed acute myocarditis about a week after first showing monkeypox lesions, according to a report published Friday in the American College of Cardiology’s journal, JACC: Case Reports.

The man said he woke up in the night feeling chest pain that radiated through his left arm. He was admitted to the hospital with signs of heart damage. However, he made a full recovery and left the hospital a week later.

Myocarditis causes serious inflammation and can result in heart failure or sudden death. It is rare but can be caused by a viral infection. In the past, cases have been linked to smallpox, which is a similar virus to monkeypox. However, myocarditis can also be caused by SARS-CoV-2, and the Portugal patient did have mild COVID two months before.

It’s not clear if monkeypox was definitely the cause of the myocarditis. While the exact link is still to be determined, the study’s lead author, Dr. Ana Isabel Pinho of São João University Hospital Centre in Porto, Portugal, said she hopes the information will have doctors on the lookout.

“We believe that reporting this potential causal relationship can raise more awareness of the scientific community and health professionals for acute myocarditis as a possible complication associated with monkeypox, and might be helpful for close monitoring of affected patients for further recognition of other complications in the future,” she said in a statement.

Monkeypox spread may be slowing

An unprecedented global outbreak of monkeypox has been ongoing since May. As of Sept. 1, there have been 52,090 cases reported in 100 countries, 93 of which had never before observed significant community spread of this disease. Leading the global case count is the United States at 19,465 cases, with confirmed positives in all 50 states, Washington, DC, and Puerto Rico. Though another strain of the monkeypox virus is considered more dangerous and has a higher fatality rate, death is rarely an outcome with Clade IIb, the version of monkeypox in the current outbreak. This year, there have been 15 monkeypox-related deaths in eight countries — just 0.03% of the reported cases. At greatest risk are those who are immunocompromised or who have certain skin conditions.

News of the Houston-area resident’s death comes just a few days after an Aug. 26 news conference during which CDC Director Rochelle Walensky said she was “cautiously optimistic” about an apparent downward trend in new cases in some hot spots, including New York City and San Francisco.

“We’ve started to see globally that we may be turning a corner,” she said. “We’re watching this with cautious optimism, and really hopeful that many of our harm reduction messages and our vaccines are getting out there and working.”

First discovered in the 1950s, monkeypox is not a new virus. It is in the same family as smallpox, though it is typically milder.

Infections are characterized by a rash, which may begin on or near the genitals, giving way to pustular-looking lesions located anywhere on the body or mucous membranes. The lesions can be few or widespread, depending upon the severity of infection. Other possible symptoms include fever, chills, swollen lymph nodes, exhaustion, muscle and headaches, and a sore or swollen throat.

People with monkeypox have reported mild to medium discomfort, although others have reported that the lesions can be painful. Most are able to tolerate the recovery period with over-the-counter medications, such as ibuprofen, to reduce fever and inflammation. Other home remedies and treatments can help the lesions, including sitz baths and cold compresses. For more intense cases, doctors might prescribe higher-powered painkillers and antibiotics to help prevent secondary infections (antibiotics can’t kill viruses).

People with severe illness from monkeypox may request an antiviral medication called tecovirimat (Tpoxx), through a special authorization process. Many individuals taking the drug have offered anecdotal reports of experiencing relief, but studies are currently underway to determine its exact effectiveness. The drug appeared to be safe and effective in a study of 25 patients recently published in JAMA; however, there was no control group and more research is needed.

The ongoing investigation of the Texas death

An autopsy will soon be performed to determine the actual cause of death for the Houston-area resident, who county public health officials described as having had “various severe illnesses.” The process could take weeks, but Harris County Judge Lina Hidalgo felt it pertinent to say something now in order to get ahead of any rumors.

“We are sharing this information to err on the side of transparency and to avoid potential misinformation about this case,” she said.

Pathologists working to determine the individual’s cause of death may be looking for certain complications known to be associated with monkeypox, including bacterial sepsis, pneumonia, and encephalitis, an infection of the brain.

“They haven’t yet revealed all that this person had, but I’m sure they will. They’ve just said that they died in this area,” said Dr. Keisha Davis, a Houston-based pathologist who is not associated with this case. “The autopsy will tell us a lot more of the story, but that will take a couple of weeks. For instance, if there was inflammation of the brain, we usually let it sit for a few days before we do it. Just the brain alone can take three to five days.”