Study: Severe Monkeypox in Hospitalized Patients — United States, August 10–October 10, 2022. Image Credit: Berkay Ataseven / Shutterstock.com

New report on the impact of monkeypox on people with HIV

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In a recent Weekly Morbidity and Mortality Reportinvestigators describe the presentation of patients severely infected with monkeypox virus (MPXV).

To study: Severe monkeypox in hospitalized patients: United States, August 10 to October 10, 2022. Image Credit: Berkay Ataseven / Shutterstock.com

Background

The United States has recorded more than 28,300 MPXV infections as of October 21, 2022.

Men who have sex with men (MSM), as well as bisexual and homosexual people, make up the majority of MPX cases. Racial and ethnic minorities, as well as people with human immunodeficiency virus (HIV) infection, have also been disproportionately affected.

About the study cohort

In the current study, the investigators describe patients from CDC practices who were hospitalized with MPXV between August 10, 2022, and October 10, 2022. In addition, they also provided complete case histories for three patients with severe manifestations of MPXV.

The US Centers for Disease Control and Prevention (CDC) provides consultation for the treatment of MPXV cases. To this end, the US CDC acquired data on patient demographics, clinical course, and outcomes during consultations with health care departments/providers.

The CDC provided consultations to 57 patients aged 18 years and older hospitalized for severe manifestations of MPXV during the specified time period. Fifty-four patients were men, and the median age of the patients was 34 years. HIV infection was documented in 47 patients, 43 of whom had a known cell group of differentiation 4 (CD4) cell.

Two patients received chemotherapy for hematologic malignancy, three were solid organ transplant recipients, and three were pregnant. More than 68% of MPXV patients were black.

Dermatological manifestations were observed in all patients. Severe mucosal lesions were identified in 39 patients. Some patients exhibited symptoms involving other organs such as the lungs, brain, eyes, or spinal cord.

Tecovirimat was administered orally in 53 patients and intravenously in 37. Thirteen patients received intravenous cidofovir and 29 received intravenous vaccinia immunoglobulin (VIGIV). Intensive care was required for 17 patients, 12 of whom ultimately died.

Patient Case Studies

A Hispanic man with no medical history was evaluated for back pain and diffuse rash in the emergency department (ED) in August 2022. The rash spread throughout his body.

Swabs were obtained from the lesions for polymerase chain reaction (PCR) testing for Orthopoxvirus (OPXV). Two days later, the test came back positive.

The individual became drowsy and required intensive care on the second day of hospitalization. The patient was intubated the next day and tecovirimat was administered.

An African-American man with acquired immunodeficiency syndrome (AIDS) developed a rash on his face, back, head, and genitalia in July 2022. Multiple clinic visits requested testing and treatment for gonorrhea, syphilis, and chlamydia. The genital lesions eventually progressed and were accompanied by urinary retention and phimosis that warranted hospitalization four weeks after the appearance of the initial rash.

The patient subsequently tested positive for MPXV and was discharged with two weeks of oral tecovirimat. The patient was readmitted due to general malaise, weight loss, new lesions on the penis and hands, and lack of appetite.

methicillin resistant Staphylococcus aureus (MRSA) bacteremia was observed during the 15 days of hospitalization. The second patient was discharged but readmitted again due to progressive necrotic lesions.

A third non-Hispanic white male patient with AIDS was evaluated for a rash on the face, hands, torso, perianal region, and feet. The MPXV test was positive and the patient was subsequently hospitalized and started on oral tecovirimat. The patient was discharged after seven days.

Three weeks after discharge, the third patient was readmitted for painful, coalescing, and necrotic lesions on the hands and feet. Despite treatment, progressive tissue necrosis led to amputation of the fourth toe of the right foot and debridement of the soft tissues of the index finger of the right hand. The lesions gradually regressed.

Both the second and third patients remain hospitalized.

Conclusions

The current study highlighted the occurrence of severe manifestations in MPXV cases, particularly among AIDS patients. Nearly a third of the patients required intensive care and a fifth succumbed to infection.

Tecovirimat was administered in most patients; however, there were delays in some patients in starting treatment. Therefore, the authors suggest that healthcare providers start MPXV-targeted therapies early for people with suspected or confirmed MPXV and those who are at risk for severe disease.

In those with severe disease or ongoing disease despite treatment, healthcare providers should consider tecovirimat treatment for longer than two weeks and escalate the therapeutic regimen to include VIGIV or cidofovir if clinically indicated.

Magazine reference:

  • Miller, MJ, Cash-Goldwasser, S., Marx, GE, et al. (2022). Severe monkeypox in hospitalized patients: United States, August 10 to October 10, 2022. Weekly Morbidity and Mortality Report. doi:10.15585/mmwr.mm7144e1

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