Severe mpox in PLWH
Data from mpox cases prior to the 2022 outbreak suggested that patients with HIV complicated by AIDS are at risk for more severe disease. As the 2022 outbreak progressed, the CDC reported that the majority of severe mpox cases occurred in PLWH, particularly in those with low CD4+T Cell counts. This growing body of data suggests PLWH with CD4+ T Cell counts less than 200 cells/mm3 are at significantly increased risk for fatal outcome (Table 1). Of the most severe cases reported, patients often present with vast necrotizing skin lesions and to develop multiorgan involvement to include the pulmonary, gastrointestinal, musculoskeletal, and central nervous systems. Many develop bacterial superinfection, sepsis and acute respiratory distress syndrome (ARDS). Reports suggest that initiation of ART is often delayed for weeks after presentation. Among the largest cohorts, mortality rates in patients with advanced HIV range from 15 to 40%. Death occurs many weeks to months after the initial presentation. These reports also highlight the phenomenon of IRIS, described as an acute worsening or spreading of a patient’s lesions and clinical deterioration approximately 2 weeks after initiation of ART. At this time, it is not clear if these cases represent true IRIS, or simply the natural progression of mpox in severely immunosuppressed patients. Notably, IRIS has been described previously with other poxvirus infections.