By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: The Centers for Disease Control and Prevention has summarized 57 cases of individuals hospitalized with severe monkeypox, most of whom were immunocompromised men and a number of whom had delayed initiation of antiviral therapy.
SOURCE: Miller MJ, Cash-Goldwasser S, Marx GE, et al. Severe monkeypox in hospitalized patients — United States, August 10-October 10, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1412-1417.
The Centers for Disease Control and Prevention (CDC) has been available to clinicians and jurisdictions for consultation on the management of patients with monkeypox and describe 57 of these assessed from Aug. 10 to Oct. 10, 2022. Their median age was 34 years (range, 20-61 years), two-thirds were Black, 95% were male, one-fifth were homeless, and 82% were infected with human immunodeficiency virus (HIV) and their CD4 count was < 50 cells/mm3 in 72% of those for whom this information was available. In addition, three (4%) patients (one of whom was infected with HIV) were receiving chemotherapy for hematologic malignancies, three (5%) were solid organ transplant recipients, and three (5%) were pregnant.
In addition to skin lesions in all patients, two-thirds had mucous membrane involvement. The lungs were affected in 12 (21%) and eyes in 12 (21%), while four (7%) had brain or spinal cord involvement. Antiviral therapy included oral tecovirimat in 53 (93%), intravenous (IV) tecovirimat in 37 (65%), vaccine immune globulin intravenous (VIGIV) in 29 (51%), and IV cidofovir in 13 (23%) — all those who received cidofovir or VIGIV also received tecovirimat.
Intensive care unit (ICU) care was required by 17 (30%) patients and 12 (21%) died. While one of these deaths was not due to monkeypox virus infection, the infection was the cause or a contributing factor in five, while six still are under adjudication.
COMMENTARY
In the current ex-Africa monkeypox outbreak, infections may be severe, but only a minority of cases in the United States require hospitalization, and fatalities are very uncommon. The CDC has reported that, as of Nov. 8, 2022, the worldwide total of cases was 78,599, with only 44 deaths. In the United States, there had been 11 fatalities among a total of 28,730 cases — 0.038%. As indicated in the CDC report reviewed here, attribution of the cause of death may be quite difficult, in part because of coexisting morbidities.
Despite these statistics, this report demonstrates that severe disease does occur and a significant contributing factor is immunocompromise, which was present in 89.5% of patients in this series. Immunocompromise was most frequently due to HIV infection. Of further importance is that one-fifth of those affected were homeless. Another important factor in some cases were delays of up to four weeks from the time of their initial presentation for medical care to the initiation of monkeypox-directed antiviral therapy, although once hospitalized, almost all patients received such drugs.
Early initiation of therapy with tecovirimat is important. The CDC also suggests that in the presence of severe disease or with progression despite treatment, consideration should be given to prolonging tecovirimat administration beyond 14 days and to consider “escalating therapy to include cidofovir or VIGIV if clinically indicated.” While this recommendation makes sense, it must be recognized that it lacks substantive supporting clinical evidence.
Finally, the CDC strongly recommends that all patients with monkeypox virus infection be tested for HIV infection and, if positive, antiretroviral therapy should be initiated.
