Intended for healthcare professionals


Monkeypox can be fatal for people with weak immune systems, CDC warns

BMJ 2022; 379 doi: (Published 28 October 2022) Cite this as: BMJ 2022;379:o2602
  1. Janice Hopkins Tanne
  1. New York

Monkeypox can have “devastating outcomes” in people who have weakened immune systems, especially those with untreated HIV, the US Centers for Disease Control and Prevention (CDC) has reported.1

The report published in Morbidity and Mortality Weekly (MMWR) said that healthcare providers should consider prompt monkeypox treatment for patients with probable or confirmed monkeypox who are at risk for severe disease, especially those with advanced HIV. Patients with suspected monkeypox should be tested for HIV when undergoing testing for monkeypox, and HIV treatment should be provided if indicated.

As of 27 October, 28 244 confirmed and probable cases of monkeypox had been reported in the US, but the epidemic has declined since its daily peak of 569 cases on 1 August. On 24 October, 62 cases were reported, then 22 cases on 25 October, and six cases on 26 October.2

Men who have sex with men comprised most of the cases, and people with HIV infection and those from racial and ethnic minority groups were disproportionately affected. Many of the infected patients were also homeless.

Jonathan Mermin, head of the CDC’s monkeypox initiative, said in a press release, “Monkeypox and HIV have collided with tragic effects. Today’s report reminds all of us that access to monkeypox and HIV prevention and treatment matters—for people’s lives and for public health.”

The patients

The MMWR report describes 57 patients aged 18 or older who were admitted to hospital with severe manifestations of monkeypox between 10 August and 10 October and for whom the CDC provided clinical consultations.

Seventeen of the 57 patients received ICU level care, and 12 died. Monkeypox was a cause of death or a contributing factor in five cases. Six deaths are under investigation to determine whether monkeypox was a causal or contributing factor, and in one death monkeypox was not a cause or contributing factor.

Of the 57 patients, 54 (95%) were male and 39 (68%) were black. Nearly a quarter (13 patients; 23%) were homeless. The median age was 34, although patients ranged in age from 20 to 61. Most patients (47; 82%) had HIV infection. Two patients, one of whom had HIV, were receiving chemotherapy for a haematological malignancy, three were recipients of solid organ transplants, and three were pregnant.

All 57 patients had severe dermatological manifestations, and 39 (68%) also had severe mucosal lesions. Some patients also had involvement of the lungs, eyes, and brain or spinal cord.

Most patients (53; 93%) received oral tecovirimat, and 37 (65%) received intravenous tecovirimat; 29 (51%) received vaccinia immune globulin intravenous (VIGIV), and 13 (23%) received intravenous cidofovir. All patients who received cidofovir or VIGIV also received tecovirimat.

Three representative cases described in the report

Patient A, a Hispanic or Latino man in his 20s with no known past medical history, was evaluated in an emergency department for back pain and a diffuse rash. Swabs from his lesions tested positive for monkeypox. Over the next week his rash involved his entire body, and he was admitted to hospital. He had fever and a diffuse rash with central ulcerations as well as eschars on his face, trunk, and extremities, oral lesions, and a left neck mass. He tested positive for HIV. He became somnolent in hospital and was transferred to the ICU. He developed resistant hypotension, had a seizure, and went into kidney failure. He required cardiopulmonary resuscitation, and a brain scan showed poor perfusion. His family decided to transfer him to comfort care, and he died.

Patient B, a black man in his 30s with AIDS who was not receiving antiretroviral therapy (ART), developed a rash on his face, head, back, and genitals. He tested positive for monkeypox. After treatment he was discharged with a urinary catheter and 14 days of oral tecovirimat. His skin lesions improved but then spread, coalesced, and developed central necrosis. A suprapubic catheter was placed. He also had methicillin resistant Staphylococcus aureus bacteraemia, atrial fibrillation, and conjunctivitis. He was transferred to the ICU and later discharged on oral tecovirimat and ART. Later he was readmitted with progressive necrotic lesions and bacterial superinfections. He was restarted on intravenous tecovirimat and continues this treatment.

Patient C, a white man in his 40s with AIDS who was not receiving ART, had a rash on his face, torso, hands, feet, and perianal area that tested positive for monkeypox. He was admitted for pain control and treated with oral tecovirimat and ART. He was discharged to continue tecovirimat treatment, but his housing and food situations were unstable, and he was readmitted with painful, coalescing, and necrotic lesions on his hands and feet. Despite intensive treatment, progressive tissue necrosis led to debridement of a finger and amputation of a toe. The monkeypox lesions gradually regressed and he was discharged, only to be readmitted a week later for unresolved lesions and severe pain. He remains in hospital on tecovirimat and ART.