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.