Successful Outcome after Treatment with Cidofovir, Vaccinia, and Extended Course of Tecovirimat in a Newly-Diagnosed HIV Patient with Severe Mpox: A Case Report

Abstract

Purpose: To report a case of severe mpox in a newly diagnosed HIV patient concerning Immune Reconstitution Inflammatory Syndrome (IRIS) and/or tecovirimat resistance and/or tecovirimat resistance and to describe the management approach in the setting of refractory disease. Case: 49-year-old man presented with 2 weeks of perianal lesions. He tested positive for mpox PCR in the emergency room and was discharged home with quarantine instructions. Three weeks later, the patient returned with disseminated firm, nodular lesions in the face, neck, scalp, mouth, chest, back, legs, arms, and rectum, with worsening pain and purulent drainage from the rectum. The patient reported being on 3 days of tecovirimat treatment, which was prescribed by the Florida department of health (DOH). During this admission, he was found to be HIV positive. A pelvic CT scan revealed a 2.5 cm perirectal abscess. Treatment with tecovirimat was continued for 14 days, along with an empiric course of antibiotics for treatment of possible superimposed bacterial infection upon discharge. He was seen in the outpatient clinic and initiated antiretroviral therapy (ART) with TAF/emtricitabine/bictegravir. Two weeks after starting ART, the patient was readmitted for worsening mpox rash and rectal pain. Urine PCR also returned positive for chlamydia, for which the patient was prescribed doxycycline. He was discharged on a second course of tecovirimat and antibiotic therapy. Ten days later, the patient was readmitted for the second time due to worsening symptoms and blockage of the nasal airway from progressing lesions. At this point, there were concerns for tecovirimat resistance, and after discussion with CDC, tecovirimat was reinitiated for the third time, with the addition of Cidofovir and Vaccinia, and showed an improvement in his symptoms. He received three doses of cidofovir and two doses of Vaccinia, and the patient was then discharged to complete 30 days of tecovirimat. Outpatient follow-up showed favorable outcomes and near resolution. Conclusion: We reported a challenging case of worsening mpox after Tecovirimat treatment in the setting of new HIV and ART initiation concerning IRIS vs. Tecovirimat resistance. Clinicians should consider the risk of IRIS and weigh the pros and cons of initiating or delaying ART. In patients not responding to first-line treatment with tecovirimat, resistance testing should be performed, and alternative options should be considered. Future research is needed to establish guidance on the role of Cidofovir and Vaccinia immune globulin and the continuation of tecovirimat for refractory mpox.

Optimal management of severe mpox in patients with uncontrolled human immunodeficiency virus

“…Among the largest cohorts, mortality rates in patients with advanced HIV range from 15% to 40% 5,7 . Death occurs many weeks to months after the initial presentation 5,7,23,27,29,30,34,36 . 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 5,27,29,36 .…”

“…While data are scarce, there appears to be no benefit to delaying ART to attenuate possible IRIS. 5,27,29,36 4. 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.…”

“…23,26 This growing body of data suggests PLWH with CD4+ T Cell counts less than 200 cells/mm 3 are at significantly increased risk for fatal outcome (Table 1). 5,7,23,[27][28][29][30][31][32][33][34][35][36][37] 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. 5,7,23,[27][28][29][30][31][32][33][34][35][36][37] Many develop bacterial superinfection, sepsis and acute respiratory distress syndrome (ARDS).…”

“…5,7,23,[27][28][29][30][31][32][33][34][35][36][37] 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. 5,7,23,[27][28][29][30][31][32][33][34][35][36][37] Many develop bacterial superinfection, sepsis and acute respiratory distress syndrome (ARDS). 5,7,29 Reports suggest that initiation of ART is often delayed for weeks after presentation.…”

Perceptions and Intention to get vaccinated against Mpox among the LGTBIQ+ Community during the 2022 outbreak: A Cross-Sectional Study in Peru

“…It has even been hypothesized that resistance to tecovirimat could develop in patients at risk of receiving a prolonged regimen, such as patients co-infected with HIV and mpox. [17]. Therefore, the development and implementation of prevention strategies against mpox in the MSM population are of high importance to avoid signi cant sequelae and fatal outcomes.…”