CDC outlines treatment considerations for severe manifestations of mpox

The CDC recently released interim treatment considerations for patients with severe manifestations of mpox.

From May 2022 (when the global mpox outbreak was identified) to January 2023, the CDC provided more than 250 U.S. mpox consultations. In a report published in the March 3 MMWR, the agency provided interim clinical treatment considerations in these cases based on data from animal models, medical countermeasures (MCMs) used for human cases of related orthopoxviruses, unpublished data, input from clinician experts, and experience during consultations and follow-up. MCMs to treat mpox include tecovirimat, brincidofovir, cidofovir, trifluridine ophthalmic solution, and vaccinia immune globulin intravenous (VIGIV).

“Randomized controlled trials and other carefully controlled research studies are needed to evaluate the effectiveness of MCMs for treating human mpox,” the authors wrote. “Until data gaps are filled, the information presented in this report represents the best available information concerning the effective use of MCMs and should be used to guide decisions about MCM use for mpox patients.”

Severe manifestations of mpox include ocular infections, neurologic complications (e.g., encephalitis, myelitis, severe headache, back or neck pain, altered mental status, seizures, or focal neurologic deficits), myopericarditis, mucosal lesion complications, and uncontrolled viral spread. The report outlined the following treatment considerations for these manifestations:

• For ocular infections, consider prompt initiation of tecovirimat and topical administration of trifluridine, although prolonged use of the latter may lead to adverse events. Clinicians can also consider prophylactic use of trifluridine in patients with mpox who are at high risk of ocular infection (e.g., those with lesions near the eye). They may consider other systemic MCMs on a case-by-case basis, as well as lubricants and topical antibiotics for symptomatic management and prevention of complications. Clinicians should obtain ophthalmology consultation, urgently for patients with eye pain, vision loss, or worsening ocular symptoms.
• Treatment of neurologic complications should involve MCMs and might involve immunomodulatory or immunosuppressive therapy. Data suggest that tecovirimat penetrates the CNS well; brincidofovir, cidofovir, and VIGIV penetrate the CNS to an extent that is either uncertain (brincidofovir) or limited (cidofovir and VIGIV). Clinicians should consider neurology consultation and investigate other neurologic diseases with similar presentations (e.g., infectious diseases such as viral encephalitides and syphilis, and autoimmune, parainfectious, and vascular conditions).
• New reports of chest pain, shortness of breath, or palpitations in a patient with ongoing or recent mpox should prompt consideration of myopericarditis. Consider providing standard of care for myopericarditis. MCMs may also play a role by limiting viral spread to myocytes or decreasing the production of viral antigens responsible for the inflammatory response. Clinicians should consider cardiology consultation and investigate other potential causes of myopericarditis.
• Complications associated with some mucosal (oral, rectal, genital, and urethral) lesions can impair activities of daily living, including eating, urination, or defecation. Clinicians should consider prompt initiation of systemic MCMs, as early and aggressive treatment may prevent complications such as intubation, urinary catheterization, or placement of enteric tubes. Symptomatic management, and particularly pain control, is important, and clinicians should consult specialists (e.g., surgery, urology, or gastroenterology) early in the clinical course.
• In moderately to severely immunocompromised patients, complications from uncontrolled viral spread can manifest as new skin lesions or worsening of existing lesions. Clinicians should optimize immune function through such interventions as effective HIV antiretrovirals and reduced immunomodulatory therapy as feasible. They should also consider prompt initiation of tecovirimat (potentially the IV formulation), possibly combined with either cidofovir or brincidofovir and VIGIV. Consider consulting experts in infectious diseases, critical care, dermatology, wound care, gastroenterology, and surgery as indicated.