Optimal Management
The optimal management of these severe cases in PLWH remains unknown.
However, based on the available published data summarized above,
recommendations from the CDC and our institutional experience, we make
the following recommendations on the management of severe mpox in PLWH.
- Upon identification of severe mpox in PLWH, we recommend consultation
with CDC and local health departments, and immediate initiation of
tecovirimat in combination with VIGIV and either cidofovir or
brincidofivor if these agents are available and not contraindicated.
While CDC guidance makes the addition of multiple agents a
consideration, we feel strongly that a combination of agents should be
employed to maximally inhibit viral replication while the immune
system regains the ability to clear the virus. None of the available
agents is viricidal, and therefore management should aim for maximal
inhibition, effectively ‘bridging’ the host into a reconstituted
state. This strategy also employs the theoretical benefits of
protecting against resistance that may result from active viral
replication in the presence of a single inhibitor, as well as
antiviral synergy. These agents should be continued at least until
lesions stop progressing and begin healing, which may take several
weeks to months.
- Eligible patients should be encouraged to enroll the STOMP Trial and
VIRISMAP, as combination antivirals against mpox does not exclude
patients from these studies.
- ART should be initiated as soon as feasible, and in accordance with
other HIV management guidance. While data are scarce, there appears to
be no benefit to delaying ART to attenuate possible IRIS.
- Patients should be evaluated for alternative etiologies of their
disease, as well as concomitant sexually transmitted infections and
opportunistic infections as recommended by other HIV management
guidance.
- Providers should perform a thorough history and physical examination
to identify all possible organ systems that may be affected but may
not be immediately apparent; these include musculoskeletal, ocular,
central nervous system, gastrointestinal, pulmonary, and
cardiovascular systems.
- In patients with suspected bacterial infection, providers should
obtain appropriate cultures and then provide empiric antibiotics. The
duration of empiric antibacterial therapy should be no longer than
what would be given for the specific diagnosis that is suspected (ie
SSTI or bacteremia) if the suspected diagnosis cannot be ruled out.
Antibiotics should not be given indefinitely. While bacterial
superinfection of mpox patients is low in the general population,
patients with uncontrolled HIV and severe disease have higher
incidence of bacterial superinfection. Bacterial infection resulting
in sepsis can also be a significant cause of death in these patients,
particularly those with anogenital and gastrointestinal lesions.
- Patients should be closely reassessed longitudinally over the full
course of their recovery. As these severe mpox patients progress, they
often develop fevers, leukocytosis, progression of lesions and new
symptoms over the course of their management. Based on the
heterogeneity of published cases, it is not clear if this progression
represents the natural course of the disease in severely
immunosuppressed hosts, or if there is a true development of IRIS. In
the limited data available, there does not appear to be a significant
difference in outcome among those who received IRIS treatment and
those who did not; nor does there appear to be any benefit to delaying
ART initiation.
- Care should be provided with a multidisciplinary approach to
comprehensively and longitudinally address the multiple complex issues
that stem from severe MPXV infection as well as any potential barriers
to treatment adherence upon discharge. Specialties likely to be
involved include: Infectious Disease, Internal Medicine, Pharmacy,
Nursing, Wound Care, Pain and Palliative Care, Neurology, General
Surgery, Orthopedic Surgery, Urology, Plastic Surgery, Ophthalmology,
Dermatology, OBGYN, Psychiatry and Social Work. Quality wound care
provided by a specialist is a critical component to this longitudinal
care.