CDC: HIV Coinfection in Over 80% of Hospitalized Monkeypox Cases

In a cohort of patients hospitalized for monkeypox, four out of five had HIV and one in five died, CDC researchers said.

Of the 57 adults hospitalized due to serious complications from monkeypox, 82.5% had HIV and 8.5% were receiving antiretroviral therapy, reported Maureen Miller, MD, of the CDC's Monkeypox Emergency Response Team, and colleagues.

Altogether, 30% of patients received intensive care unit (ICU)-level care, and 12 patients died. Monkeypox was either a cause of death or a contributing factor in five of the deaths, while most of the other deaths are still under investigation, they noted in the Morbidity and Mortality Weekly Report.

Last month, the CDC issued a health advisory warning healthcare providers to look out for severe cases of monkeypox in patients who are immunocompromised or co-infected with HIV, and urged "prompt monkeypox treatment" for all patients with probable or confirmed monkeypox who are at risk for severe disease -- especially those with advanced HIV.

Miller and co-authors recommended that providers "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."

They suggested that providers consider starting monkeypox treatment early, possibly even before test results are received or before "severe manifestations" emerge.

If clinically indicated, the researchers added that providers should consider extending the course of tecovirimat (Tpoxx) beyond 14 days in cases of severe disease, or for patients with ongoing disease despite treatment, and consider either cidofovir or vaccinia immune globulin intravenous (VIGIV) as well.

"Monkeypox and HIV have collided with tragic effects," said Jonathan Mermin, MD, MPH, the CDC's Monkeypox Incident Commander, in a statement. This report "reminds all of us that access to monkeypox and HIV prevention and treatment matters -- for people's lives and for public health."

From August 10 to October 10, CDC provided consultation for 57 adults who were hospitalized with severe manifestations of monkeypox, collecting data on patient demographics, clinical course, and outcomes.

The majority of patients were men (95%) and Black (68%), and 23% were experiencing homelessness. Median age was 34 years.

Of the 43 HIV patients with a documented CD4 count, 72% had a count <50 cells/mm³. Two patients (one with HIV) were receiving chemotherapy for a hematologic malignancy, three were solid organ transplant recipients, and three were pregnant.

One of the representative cases included in the report was a Hispanic or Latino man in his 20s who tested positive for monkeypox, but had no known medical history.

"He was admitted to a hospital after being evaluated for dyspnea on exertion, dry cough, persistent back pain, and painful left neck swelling," Miller and team noted. He had a fever of 102.8°F, a diffuse rash that covered most of his body, and oral lesions.

Lab results came back positive for HIV. He had previously tested positive in 2020, but was "lost to follow-up," according to state reporting. The patient subsequently developed "vasopressor-resistant hypotension, experienced a seizure, and went into kidney failure."

Despite being intubated, receiving cardiopulmonary resuscitation, intravenous tecovirimat, vasopressors, antiepileptics, antibiotics, antifungals, and one dose of VIGIV, a brain scan showed poor perfusion and the patient later died.

In a second case detailed in the report, another hospitalized patient with monkeypox had one of his toes amputated due to painful necrotic lesions.

As cases included in this report were "passively identified" through consultations requested by clinicians or jurisdictions, they may not be generalizable to all patients with severe monkeypox. Miller and colleagues also noted that "observed morbidity and mortality might have been related to factors apart from or in addition to monkeypox, including HIV-related opportunistic infections."

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