Infectious Diseases | November 2, 2022 | FREE
Most ACP Hospitalist content is available exclusively to ACP Members. This article is free to the public.

Most U.S. patients hospitalized with severe monkeypox had HIV infection

Of 57 adult patients who were hospitalized with severe manifestations of monkeypox during the current outbreak, 82% had HIV infection, 30% received ICU-level care, and 21% died, according to a recent CDC report. All had dermatologic manifestations.

Most patients hospitalized with severe manifestations of monkeypox during the current outbreak in the U.S. had HIV infection, according to a recent CDC report.

From Aug. 10 to Oct. 10, the CDC provided clinical consultations for 57 adult patients who were hospitalized with severe manifestations of monkeypox. Most patients were male (95%), and 68% were Black, with a median age of 34 years (range, 20 to 61 years). Thirteen (23%) were experiencing homelessness. Overall, 47 (82%) patients had HIV infection, four (9%) who were receiving antiretroviral therapy before monkeypox diagnosis. Thirty-one (72%) of the 43 with a known CD4 count had a count less than 50 CD4 cells/mm3. Sixteen (28%) had coinfection with a sexually transmitted infection. Two patients (4%), one who had HIV infection, were undergoing chemotherapy for a hematologic malignancy, three (5%) were solid-organ transplant recipients, and three (5%) were pregnant. The findings, as well as descriptions of three clinically representative cases with AIDS, were published Oct. 26 by MMWR.

All patients had severe dermatologic manifestations, and 39 (68%) also had severe mucosal lesions. Some experienced involvement of other organs, such as the lungs (21%), eyes (21%), and brain or spinal cord (7%). Fifty-three (93%) patients received oral tecovirimat, and 37 (65%) received IV tecovirimat; 29 (51%) received vaccinia immune globulin intravenous (VIGIV), and 13 (23%) received IV cidofovir. All patients who received VIGIV or cidofovir also received tecovirimat. Overall, 17 (30%) patients received ICU-level care, and 12 (21%) died. Monkeypox was a cause of death or contributing factor in five deaths and was not in one death, with six deaths remaining under investigation.

Clinicians should test all sexually active patients with suspected monkeypox for HIV at the time of monkeypox testing, unless a patient is already known to have HIV infection, the CDC said. In patients with or at risk for severe monkeypox, clinicians should consider close clinical monitoring, early treatment with available medical countermeasures, and extension or escalation of therapy as indicated, according to the CDC.

“Although most monkeypox cases during the ongoing outbreak have been self-limited, this report highlights the occurrence of severe manifestations of monkeypox in the United States, particularly in persons with AIDS. … The occurrence of severe manifestations of monkeypox in patients who were most commonly immunocompromised because of AIDS highlights the importance of engaging all persons with HIV in sustained care and ending the HIV epidemic,” the researchers wrote.

A recent Q&A in ACP Hospitalist offered guidance on hospital care for monkeypox.