Mpox and HIV: a Narrative Review

Mpox: Characterization and clinical outcomes of patients in Colombian healthcare institutions

Introduction

In 2022, the world experienced a monkeypox outbreak caused by the Clade IIb strain of the virus. While this outbreak had widespread effects, more information is needed on mpox's specific impact in Colombia, particularly regarding how it is managed, its burden, and its epidemiology. This research seeks to examine the medical context, clinical presentation, and health outcomes of individuals diagnosed with mpox infection, with a particular focus on those with HIV in Colombia.

Methods

This retrospective study was conducted in fourteen Health institutions in Colombia based on computerized clinical records from Jan 2022 to Dec 2023. Clinical and epidemiological characteristics were collected from diagnosis until discharge (or death). Participants in the study were diagnosed through molecular methods (PCR) and their clinical evolution was tracked through hospital and/or outpatient medical records. Registered variables were based on the mpox 2023 Case Report Form (2023 - CRF) proposed by the World Health Organization.

Results

One thousand four hundred thirteen (1413, 97.2 % male) individuals, including 2.6 % identified as healthcare workers, were included in this study. The majority (54 %, 764/1413 individuals) were persons living with HIV (PWH) and almost one-third of them (30.1 %, n = 284) of participants had concomitant sexually transmitted diseases and HIV, with syphilis being the most prevalent (20.4 %), followed by Neisseria gonorrhoeae (16.4 %). Complications were infrequent, with cellulitis being the most common, and no individuals received mpox-specific treatment or vaccination. Although all individuals had skin lesions distributed across various body regions, differences were noted in lesion distribution among women. Those living with HIV showed higher emergency department attendance and reported having known mpox contacts. While complications were rare, with cellulitis being the most common, women living with HIV showed a higher rate of emergency room visits and known mpox contacts. Although not statistically significant, gastrointestinal, musculoskeletal, psychological, respiratory, and STI symptoms, including syphilis and urethritis, were more common in the virologically non-suppressed HIV group. At the same time, proctitis was more prevalent in the suppressed group. No significant differences were found based on CD4 count, using 200 cells/mm3 in PWH.

Conclusion

Over half of the participants were people living with HIV (PWH), with a significant presence of STIs like syphilis. While skin lesions and complications varied, no significant differences were linked to CD4 count or viral load suppression. Mpox symptomatology was not significantly associated with unsuppressed viral loads or low CD4 levels, highlighting the need for further research.

Mpox and the impact on people with HIV

PURPOSE OF REVIEW

This review explores the intersection of Mpox and HIV, highlighting clinical manifestations, immune evasion mechanisms, epidemiological challenges, and prevention strategies. People with HIV (PWH), particularly those with low CD4 + cell count, face severe Mpox outcomes. Prevention relies on education, vaccination, and early detection. Integrating Mpox management into HIV care systems is vital.

RECENT FINDINGS

Since May 2022, Mpox caused by Orthopoxvirus monkeypox (MPV) Clade IIb, has affected 126 countries. In 2024, Clade Ib emerged in the Democratic Republic of Congo, leading to its declaration as a Public Health Emergency of International Concern (PHEIC). Research on MPV-HIV co-infections has provided genomic insights and protective strategies for PWH. Antivirals like tecovirimat show promise despite emerging resistance concerns.

SUMMARY

The global Mpox outbreak caused by Clade IIb and the emergence of Clade Ib underscores its growing threat. Mpox disproportionately impacts PWH, leading to severe outcomes and higher fatality rates. This review emphasizes clinical challenges, genomic advances, and prevention strategies. Enhanced surveillance, vaccination, and tailored therapies are essential to addressing this evolving health crisis.

Psychosocial and Behavioral Impacts of the Mpox Outbreak among People with and without HIV in the United States

Over 32,000 mpox cases were identified in the United States (US) within one year of the start of the global outbreak in 2022. Research on how the mpox outbreak affected individuals' lives is limited. We analyzed qualitative and quantitative cross-sectional survey data collected from 60 participants in August 2022 to (1) describe mpox-related psychosocial and behavioral impacts among adults in the US and (2) explore differences in mpox-related impacts by HIV status. Results indicate that the outbreak affected both people with HIV (PWH) and people without HIV (PWOH) in our sample, while also highlighting the unique experience of PWH. The majority of participants reported that they felt at risk, experienced negative impacts across multiple life domains, changed aspects of their behavior, and anticipated mpox-related stigma. These findings can be used to inform the public health response in the event of future mpox outbreaks.

Immunohistochemical Analyses of Skin Lesions with Monkeypox Virus A29 and A35 Antibodies: A Novel Insight for Clinical-Histopathological Forms

The aim of this study was to describe the clinical, histopathological, and immunohistochemical characteristics of monkeypox (MPX) and offer meaningful insights into the clinicopathological characteristics. Eight males who have sex with males and were diagnosed with MPX based on positive results from MPX virus (MPXV)-specific polymerase chain reaction were recruited. Skin biopsies were obtained from four selected lesions, including typical and atypical forms. Histopathological examinations of atypical solitary ulceration revealed infiltrating inflammatory cells, predominantly plasma cells and lymphocytes forming a "sleeve" around the superficial vessels of the dermis. These features may be misinterpreted as indicative of cutaneous syphilis. In addition, typical pustular lesions had a central necrotic epidermis accompanied by a perivascular inflammatory infiltrate dominated by neutrophils, as well as ballooning and reticular degeneration of keratinocytes. Additionally, multinucleated keratinocytes and eosinophilic cytoplasmic inclusions (Guarnieri bodies) were observed. Importantly, this study represents a pioneering report on the immunohistochemical localization of MPXV A29 and A35 proteins in skin lesions, distinguishing it from previous studies that focused on detecting vaccinia virus proteins. The anti-MPXV A29 antibody had intense cytoplasmic staining, specifically within the affected keratinocytes in the adjacent epidermis and hair follicles, thereby contributing to the diagnosis of MPX, particularly in individuals with atypical skin lesions.

Mpox: there is still risk of global outbreak

Mpox is an emerging zoonosis that was first described in African animals, including monkeys, small rodents, and Gambian marsupial rats. It has since been identified as a sexually transmitted infection among humans. The disease is characterized by an incubation period ranging from 5 to 21 days, with the prodromal phase typically presenting nonspecific symptoms. The incubation period is followed by the development of the characteristic vesicular skin lesions that are the hallmarks of Mpox. Over the years, small outbreaks of Mpox have occurred regularly in Central and West Africa. In July 2022, the World Health Organization (WHO) declared the outbreak a Public Health Emergency of International Concern (PHEIC), due to the rapid spread of the virus in non-endemic countries. On May 11, 2023, WHO declared the end of the Mpox emergency, considering a significant decline in reported cases. As of October 2024, the true impact of this infection on international public health remains unclear.

Mpox and oral health among children in Africa

Much like it has historically, recent mpox outbreaks in Africa have significantly affected children and highlight major public health challenges, including oral healthcare in pandemic responses. The global 2022 outbreak saw an unprecedented number of mpox cases outside Africa, however children were a minority, constituting less than 2%, with the vast majority of cases reported among adult men who have sex with men. However, African countries continue to report high proportions of pediatric mpox cases, particularly Clade 1 in Burundi, the DRC, and the Congo, and Clade 2 in Nigeria. Oral manifestations of mpox such as ulcers and lesions on the lips and tongue are common and can precede skin rash, making early diagnosis challenging, especially in low-resource settings. Misdiagnosis is also a risk due to the similarity of mpox oral lesions to common pediatric exanthems and enanthems. Oral and other manifestations so mpox among affected children in Africa may be worsened due to delayed treatment and increased morbidity from high rates of malnutrition and immunosuppression, including due to HIV. This paper explores the implications of mpox on the oral health of children in Africa, emphasizing the need for improved surveillance, early detection, and the integration of the mpox response into existing child health programs. Child-focused clinical and public health research, healthcare worker training, and accessible, child-friendly diagnostic tools will be crucial for mitigating the impact of mpox on this vulnerable population.

Early Diagnosis and Monitoring of Adaptive Immune Response in a Cohort of Mild Mpox Patients During the 2022 Wave

Our study wanted to describe the kinetics of serological and adaptive immune responses in mpox patients.

METHODS

Fourteen patients with laboratory-confirmed mpox were tested at different time points after the symptom onset. An immunofluorescence assay was performed to evaluate the seroconversion kinetics of specific IgA, IgM, and IgG. Moreover, the characterization of the adaptive immunological profile of T- and B-cells was performed.

RESULTS

The antibody kinetics revealed the faster and more effective seroconversion of specific IgA than IgM. Moreover, we detected an increase in Active memory B cells and CD8+ cells in the early phases of infection, and a reduction in CD4+ T-cells in the mpox patients with respect to the controls and found the presence of higher levels of Treg cells in the HIV+ patients in the early phase of infection.

CONCLUSION

Our data highlight the relevance of specific IgA testing early after the symptom onset, suggesting a possible role as a marker in early diagnosis, especially in close contact subjects. Furthermore, the different maturation states of effector cells in HIV+ patients, together with high Treg levels, may lead us to better understand the role of MPXV-HIV co-infection and identify potential cellular markers to monitor the excessive immune activation involved in mpox disease progression.

Monkeypox-related knowledge and vaccination willingness among HIV-diagnosed and -suspected males: a cross-sectional survey in Changsha

Objective

This study aimed to update baseline data on monkeypox (mpox)-related knowledge and vaccination willingness among human immunodeficiency virus (HIV) diagnosed and suspected males.

Methods

The cross-sectional survey was conducted in Changsha, a provincial capital in China, during 5 JULY to 5 SEPTEMBER 2023. Among the three study groups, the participants in the "previously diagnosed" group were recruited from a cohort of HIV-infected patients. The "newly diagnosed" and the "suspected" groups were recruited from the outpatients and grouped according to their confirmatory test results. The the exploratory factor analysis was firstly applied to capture the latent structure of participants' response to the questionnaire about monkeypox. The component and factor scores were compared between groups using the Kruskal-Wallis H tests. The chi-square test was then used to assess the difference of mpox vaccination willingness between MSM and non-MSM in each group. Finally, multivariate logistic regression analysis was performed to identify the determinants of vaccination willingness.

Results

A total of 481 males were included in the final analysis. The results revealed that there was a gap in knowledge about monkeypox between the three participant groups. The vaccination willingness rate of HIV-infected participants was above 90%, while the rate in the HIV-suspected group was 72.60%. Multivariate logistic regression analysis revealed that the previously diagnosed group (adjusted odds ratio [aOR] = 0.314, 95% confidence interval [CI]: 0.105-0.940) and the suspected group (aOR = 0.111, 95% CI: 0.034-0.363) had a lower level of vaccination willingness and they were referred to the newly diagnosed group. Participants in the age groups ranging 25-34 (aOR = 0.287, 95% CI: 0.086-0.959) and 35-44 (aOR = 0.136, 95% CI: 0.039-0.478) years showed a lower level of vaccination willingness, referred to the 15-24 year age group. A better knowledge about monkeypox was associated with a higher level of vaccination willingness (aOR = 1.701, 95% CI: 1.165-2.483). Additionally, a considerable percentage of heterosexual individuals in each group indicated their acceptance of monkeypox vaccines.

Conclusion

An overall high level of vaccination willingness was observed among HIV-infected and-suspected male individuals with disparities noted among those with different HIV infection status, knowledge levels of monkeypox, and age. Addressing the existing knowledge gap and engaging people with persistent risks-regardless of their sexual orientation-for a timely HIV diagnosis may facilitate vaccine-based mitigation measures against monkeypox.

Understanding the impact of HIV on mpox transmission in the MSM population: A mathematical modeling study

The recent mpox outbreak (in 2022-2023) has different clinical and epidemiological features compared with previous outbreaks of the disease. During this outbreak, sexual contact was believed to be the primary transmission route of the disease. In addition, the community of men having sex with men (MSM) was disproportionately affected by the outbreak. This population is also disproportionately affected by HIV infection. Given that both diseases can be transmitted sexually, the endemicity of HIV, and the high sexual behavior associated with the MSM community, it is essential to understand the effect of the two diseases spreading simultaneously in an MSM population. Particularly, we aim to understand the potential effects of HIV on an mpox outbreak in the MSM population. We develop a mechanistic mathematical model of HIV and mpox co-infection. Our model incorporates the dynamics of both diseases and considers HIV treatment with anti-retroviral therapy (ART). In addition, we consider a potential scenario where HIV infection increases susceptibility to mpox, and investigate the potential impact of this mechanism on mpox dynamics. Our analysis shows that HIV can facilitate the spread of mpox in an MSM population, and that HIV treatment with ART may not be sufficient to control the spread of mpox in the population. However, we showed that a moderate use of condoms or reduction in sexual contact in the population combined with ART is beneficial in controlling mpox transmission. Based on our analysis, it is evident that effective control of HIV, specifically through substantial ART use, moderate condom compliance, and reduction in sexual contact, is imperative for curtailing the transmission of mpox in an MSM population and mitigating the compounding impact of these intertwined epidemics.

Effectiveness of Tecovirimat in Mpox Cases: A Systematic Review of Current Evidence

Mpox, formerly known as monkeypox, has re-emerged as a significant global health concern, particularly during the widespread outbreak of 2022. As an orthopoxvirus related to the eradicated smallpox virus, mpox has been primarily managed with smallpox vaccines and treatments, including the antiviral agent Tecovirimat. This systematic review aims to evaluate the effectiveness and safety of Tecovirimat in treating mpox, focusing on its use during the 2022 outbreak, especially among high-risk populations, including men who have sex with men and people living with HIV. We conducted a comprehensive search across databases, such as Embase, PubMed, and Web of Science, up to August 30, 2024. The selection involved a two-stage review process utilizing the Nested Knowledge platform, which helped streamline the screening and data extraction. We included studies that focused on the clinical efficacy and safety of Tecovirimat in human patients with confirmed mpox infections. Our analysis mainly synthesized data narratively due to the heterogeneity of study designs and outcomes. Fifteen studies met the inclusion criteria, providing data on 1031 mpox cases. The preliminary analysis of the PALM 007 RCT indicated that tecovirimat did not significantly outperform placebo in lesion resolution for all patients. Lesions healed faster than expected, regardless of tecovirimat or placebo treatment. A lower mortality rate of 1.7% among those enrolled in the PALM 007 RCT was observed, compared to the general mpox mortality rate of 3.6% or higher in the DRC. Observational studies revealed that early administration of Tecovirimat, especially within the first week of symptom onset, significantly improves symptom resolution, reduces the severity of the disease, and decreases the likelihood of hospitalization and complications in observational studies. However, the impact on viral clearance was inconsistent, and some studies suggested limited efficacy in severely immunocompromised patients. Regarding safety, Tecovirimat was generally well-tolerated as indicated by the RCT; however, mild adverse effects such as fatigue, headache, and nausea were commonly reported among observational studies. Serious adverse events were rare but included elevated liver enzymes and psychiatric symptoms, particularly in patients with pre-existing conditions. Tecovirimat demonstrates some potential benefits in treating mpox, particularly when administered early. The PALM 007 RCT failed to meet the efficacy point. Tecovirimat is generally well-tolerated with a favorable safety profile, although monitoring is advisable for those with existing liver or renal conditions. Despite promising results, further large-scale randomized controlled trials are needed to fully ascertain the drug's effectiveness across diverse populations and to explore its impact on viral clearance and transmission dynamics.

Characterization of a plant-derived monoclonal antibody targeting extracellular enveloped virions of Monkeypox virus

In 2022, the global outbreak of monkeypox virus (MPXV) with increased human-to-human transmission triggered urgent public health interventions. Plant-derived monoclonal antibodies (mAbs) are being explored as potential therapeutic strategies due to their diverse mechanisms of antiviral activity. MPXV produces two key infectious particles: the mature virion (MV) and the extracellular enveloped virion (EV), both essential for infection and spread. Effective therapies must target both to halt replication and transmission. Our prior research demonstrated the development of a potent neutralizing mAb against MPXV MV. This study focuses on developing a plant-derived mAb targeting MPXV EV, which is critical for viral dissemination within the host and generally resistant to antibody neutralization. Our findings reveal that the mAb (H2) can be robustly produced in Nicotiana benthamiana plants via transient expression. The plant-made H2 mAb effectively targets MPXV EV by binding specifically to the A35 MPXV antigen. Importantly, H2 mAb shows notable neutralizing activity against the infectious MPXV EV particle. This investigation is the first to report the development of a plant-derived anti-EV mAb for MPXV prevention and treatment, as well as the first demonstration of anti-MPXV EV activity by an mAb across any production platform. It highlights the potential of plant-produced mAbs as therapeutics for emerging infectious diseases, including the MPXV outbreak.

Sexually Transmitted Infections in People with Human Immunodeficiency Virus

Sexually transmitted infections (STIs) are more commonly seen in patients with human immunodeficiency virus (PWH). Routine sexual history taking and appropriate multisite screening practices support prompt identification and treatment of patients, which in turn reduces morbidity and spread of STIs including HIV. Nucleic acid amplification testing has high accuracy for diagnosing many of the major STIs. Diagnosis of syphilis remains complex, requiring 2 stage serologic testing, along with provider awareness of the myriad symptoms that can be attributable to this disease. Prevention through mechanisms such as vaccines and postexposure prophylaxis hold promise to reduce the burden of STIs in PWH.

The impact of Mpox virus incidence and Mpox virus first-dose vaccination on recent HIV testing

Understanding the impact of Mpox incidence and Mpox first dose vaccination on recent HIV testing is critical to better address both epidemics. We conducted a regression analysis of Mpox incidence and Mpox first dose vaccinations with recent HIV testing during the 2022 Mpox epidemic. We found that increased Mpox first dose vaccination was associated with a decrease in recent HIV testing in men but not women. Mpox incidence was not associated with changes in HIV testing.

Sexually transmitted diseases and HIV co-infection among adult male patients in the 2022 monkeypox outbreak: a systematic review and meta-analysis

This meta-analysis estimates sexually transmitted disease (STI) and HIV rates in male monkeypox patients during the 2022 outbreak. The study examines contextual factors that increase monkeypox risk. A systematic review of PubMed/Medline, Scopus, and Google Scholar was conducted to find observational studies on monkeypox patients' demographics and medical characteristics from the 2022 outbreak. This review's meta-analysis followed the System for the Unified Management, Assessment, and Review of Information - Joanna Briggs Institute (SUMARI JBI) guidelines. All HIV and STI prevalence data for male monkeypox patients was exported into the SUMARI JBI. For point prevalence of HIV and STIs, we used the Freeman-Tukey-type arcsine square root transformation to stabilize raw proportion variances. A fixed-effects model weighted and pooled all estimates by inverse variance. We then used a random model to account for sampling variation and reported fixed-effect model effect size heterogeneity across studies. Study heterogeneity was measured using the I2 test statistic and P-values. I2 test results were interpreted as low (25%), moderate (50%), and high (75%). Six Spanish and English studies qualified. These studies included 541 male monkeypox patients, 214 of whom had HIV and 255 with other STIs. HIV prevalence was estimated at 40% (95% CI = 0.31%, 0.50%; ᵡ2=15) and STIs at 43% (95% CI = 25%, 61%; ᵡ2=118). Overall, analyses showed moderate to high heterogeneity. Four in ten male monkeypox patients in 2022 had HIV or other STIs. To prevent HIV and other STIs, public health measures should target male and female monkeypox patients.

Two noncompeting human neutralizing antibodies targeting MPXV B6 show protective effects against orthopoxvirus infections

The recent outbreak of mpox epidemic, caused by monkeypox virus (MPXV), poses a new threat to global public health. Here, we initially assessed the preexisting antibody level to the MPXV B6 protein in vaccinia vaccinees born before the end of the immunization program and then identified two monoclonal antibodies (MAbs), hMB621 and hMB668, targeting distinct epitopes on B6, from one vaccinee. Binding assays demonstrate that both MAbs exhibit broad binding abilities to B6 and its orthologs in vaccinia (VACV), variola (VARV) and cowpox viruses (CPXV). Neutralizing assays reveal that the two MAbs showed potent neutralization against VACV. Animal experiments using a BALB/c female mouse model indicate that the two MAbs showed effective protection against VACV via intraperitoneal injection. Additionally, we determined the complex structure of B6 and hMB668, revealing the structural feature of B6 and the epitope of hMB668. Collectively, our study provides two promising antibody candidates for the treatment of orthopoxvirus infections, including mpox.

Mpox across countries from Central and Eastern Europe - 2022 outbreak

BACKGROUND

The aim of the study was to assess socio-demographical characteristics, clinical presentation, and outcomes in patients diagnosed with mpox.

METHODS

A survey on patients diagnosed with mpox was performed in 14 countries from Central and Eastern Europe. Data was compared according to HIV status and country of origin (EU vs. non-EU). Mpox diagnosis was confirmed by RT-PCR from oropharyngeal swabs, skin lesions, and other body fluids.

RESULTS

Out of 154 patients confirmed with mpox in 2022, 99.3% were males, with a median age (years) of 35 (IQR 30-39), 90.2% MSM and 48.7% PLWH. Compared to HIV-negative subjects, PLWH had more frequent high-risk behaviours:chemsex (p = 0.015), group sex (p = 0.027), and a history of sexually transmitted infections (STIs) (p = 0.004). Persons from EU were more often PLWH (p = 0.042), MSM (p < 0.0001), had multiple sexual partners (p = 0.025), practiced chemsex (p = 0.008) or group-sex (p = 0.005) and had more often history of STIs (p < 0.0001). The median CD4 cell count/mL at mpox diagnosis was 713 (IQR 486-996) and 73.5% had undetectable HIV VL. The commonest clinical features were fever (108 cases), lymphadenopathy (78), and vesiculo-pustular rash: penile (76), perianal (48), limbs (67). Fifty-one (31%) persons were hospitalized due to complications or epidemiological reasons. Three patients received tecovirimat or cidofovir. The outcome was favorable for all patients, including 4 with severe forms.

CONCLUSIONS

Mpox was diagnosed predominantly in young MSM, with high-risk behaviors and history of STIs. Effective contact tracing and vaccination are important strategic pillars to control mpox outbreaks.

Prior Sexually Transmitted Infections and HIV in Patients With Mpox, Chicago, Illinois (June 2022-March 2023)

HIV is associated with severe mpox. Sexually transmitted infections (STIs) could facilitate mpox transmission. We estimated HIV and STI frequency among patients with mpox and compared characteristics associated with mpox severity. Mpox cases during 1 June 2022 to 31 March 2023 were matched to Illinois HIV/AIDS surveillance data. Among 1124 patients with mpox, 489 (44%) had HIV and 786 (70%) had prior or concurrent STI; 307 (39%) had ≥3 STI episodes. More patients with mpox who were living with HIV were hospitalized than those without HIV (10.3% vs 4.1%, P < .001). STI screening visits are opportunities to vaccinate against mpox and provide HIV prophylaxis or treatment.

Concurrent Sexually Transmitted Infections with Mpox Infections: A Brief Review

Mpox is a viral zoonotic infection endemic to countries in Central and West Africa. The outbreak that began in May 2022 is novel for its global spread and transmission through sexual encounters. Research of this outbreak shows a high rate of concurrent sexually transmitted infections (STIs) in patients with mpox, highlighting the need to consider STIs in mpox management, and to raise awareness of historically high levels of STIs caused by inadequacies in sexual health care. It is critical to prioritize sexual health and address health disparities to control current transmission of infections and prevent future outbreaks.

Assessment of Knowledge and Concern of People Living with HIV Regarding Human Mpox and Vaccination

INTRODUCTION

Mpox virus is an orthopoxvirus that causes the zoonotic infectious disease known as mpox. The disease can also spread from humans to humans. It can be transmitted through contact with bodily fluids, lesions on the skin, or internal mucosal surfaces.

METHOD

The number of mpox cases increased during the COVID-19 pandemic. Early diagnosis and prompt management of mpox are critical in people living with HIV (PLHIV). In this study, a cross-sectional survey was conducted among PLHIV followed at the outpatient clinic between 20 April-20 August 2023. A questionnaire was used to assess the knowledge and anxiety levels of patients as well as their opinions about vaccination against mpox. The severity of symptoms in the past two weeks was assessed using the Generalised Anxiety Disorder 7-item scale. A total of 203 PLHIV were interviewed for this survey study.

RESULT

The mean age was 39.37±11.93. The majority of them were male (86.7%), and 41.4% were men who have sex with men (MSM). Only 21 of the surveyed participants (10.4%) had a "good knowledge" score about mpox. The mean knowledge score on human Mpox was 2.05 (min:0-max:8), and 107 (52.7%) had a score of 0.

CONCLUSION

The future study should focus on continuous education, promoting awareness through programs and establishing measures to successfully overcome identified variables that contribute to mpox pandemic understanding and attitudes. Applying the lessons learned from the COVID-19 pandemic will help the management of mpox virus.

Mapping the Landscape of Health Research Priorities for Effective Pandemic Preparedness in Human Mpox Virus Disease

The global re-emergence of monkeypox (Mpox) in non-endemic regions in 2022 has highlighted the critical importance of timely virus detection and robust public health surveillance in assessing outbreaks and their impact. Despite significant Mpox research being conducted worldwide, there is an urgent need to identify knowledge gaps and prioritize key research areas in order to create a roadmap that maximizes the utilization of available resources. The present research article provides a comprehensive mapping of health research priorities aimed at advancing our understanding of Mpox and developing effective interventions for managing its outbreaks, and, as evidenced by the fact that achieving this objective requires close interdisciplinary collaboration. The key research priorities observed were identifying variants responsible for outbreaks; discovering novel biomarkers for diagnostics; establishing suitable animal models; investigating reservoirs and transmission routes; promoting the One Health approach; identifying targets for vaccination; gaining insight into the attitudes, experiences, and practices of key communities, including stigma; and ensuring equity during public health emergencies. The findings of this study hold significant implications for decision making by multilateral partners, including research funders, public health practitioners, policy makers, clinicians, and civil society, which will facilitate the development of a comprehensive plan not only for Mpox but also for other similar life-threatening viral infections.

Characteristics of Mpox Infections in Louisiana in the 2022 Outbreak

The 2022 outbreak of mpox in Louisiana was limited to just >300 cases, perhaps an unexpected outcome given the state's high rates of HIV and other sexually transmitted infections (STIs). We aimed to describe the local outbreak within two health centers in the New Orleans region, partnering with the Louisiana Department of Health to offer additional statewide data. We reviewed charts of persons testing positive for mpox in New Orleans from July to November 2022 at two local health centers that together accounted for half of local cases. We abstracted data on HIV status, immune function [CD4 count, viral load (VL)], antiretroviral therapy regimen, symptoms and severity of infection, vaccination status, and whether tecovirimat was administered. We present local data relative to statewide data (July 2022-January 2023). Of 103 individuals in our network for whom charts were reviewed, 96 (93%) identified as male, 52 (50%) were Black, and 69 (67%) had HIV, including 12 (17%) with uncontrolled HIV (CD4 < 200 cells/mm3 or VL >200 copies/mL). The most common presenting symptoms were rash (n = 71, 69%), fever (n = 36, 35%), and rectal pain (n = 33, 32%). Of six (6%) patients hospitalized, four (67%) were persons with HIV (PWH). Two were hospitalized for severe mpox infection with >100 lesions at presentation; both were PWH, and one had uncontrolled infection. Across the state, 307 cases have been identified and 24 have been hospitalized. Of those hospitalized, 18 (75%) were PWH, including 9 (50%) with uncontrolled HIV. The demographic data from Louisiana, a state with high prevalence of STIs and HIV/AIDS, are consistent with prior reports describing the 2022 mpox outbreak. Our results contribute to accumulating data on the severity of infection in individuals with HIV-related immunocompromise.

Differences in pathogenicity among the mpox virus clades: impact on drug discovery and vaccine development

Since May 2022, mpox virus (MPXV) has attracted considerable attention due to a multi-country outbreak. Marked differences in epidemiology, transmission, and pathology between the 2022 global mpox outbreak (clade IIb) and classical mpox disease, endemic in Africa (clades I and IIa) have been highlighted. MPXV genome analysis has identified the genomic changes characterizing clade IIb and the drivers of MPXV rapid evolution. Although mpox cases have largely declined, MPXV cryptic transmission and microevolution continues, which may lead to an MPXV of unpredictable pathogenicity. Vaccines and antivirals developed against variola virus, the agent that caused the extinguished plague smallpox, have been used to contain the 2022 mpox outbreak. In this review article, recent findings on MPXV origin and evolution and relevant models able to recapitulate differences in MPXV pathogenicity, which are important for drug and vaccine development, are discussed.

A Case of Severe Mpox Complicated with Streptococcus pyogenes Sepsis in a Patient with HIV Infection

Since May 2022, a global outbreak of human Mpox has rapidly spread in non-endemic countries. We report a case of a 34-year-old man admitted to hospital for a six-day history of fever associated with vesiculo-pustular rash involving the face, limbs, trunk and perianal region, lymphadenopathy and severe proctitis and pharyngitis. He was HIV-positive and virologically suppressed by stable antiretroviral therapy. On admission, Mpox virus-specific RT-PCR was positive from multiple samples. Additionally, blood cultures yielded Streptococcus pyogenes, prompting a 14-day-course of penicillin G and clindamycin. Due to the worsening of proctitis along with right ocular mucosa involvement, tecovirimat treatment was started with a rapid improvement in both skin and mucosal involvement. The patient was discharged after 21 days of hospitalization and the complete clinical resolution occurred 38 days after symptom onset. This is a case of Mpox with extensive multi-mucosal (ocular, pharyngeal and rectal) and cutaneous extension and S. pyogenes bacteraemia probably related to bacterial translocation from the skin or oral cavity that was eased by Mpox lesions/inflammation. The HIVinfection, although well controlled by antiretroviral therapy, could have played a role in the severe course of Mpox, suggesting the importance of a prompt antiviral treatment in HIV-positive patients.