Representative Case Descriptions
Patient A. In August 2022, a Hispanic or Latino man in his 20s with no known past medical history was evaluated at an emergency department for back pain and a diffuse rash (location not specified). He was prescribed a course of prednisone for the back pain. Swabs were taken from the lesions to test for Orthopoxvirus (OPXV) by PCR, and the results were positive two days later. Over the next week, the patient’s rash progressed to involve his entire body. He was admitted to a hospital after being evaluated for dyspnea on exertion, dry cough, persistent back pain, and painful left neck swelling. On admission, he was febrile (102.8°F [39.3°C]), and he had a diffuse rash with central ulcerations as well as eschars on his face, trunk, and extremities; oral lesions; and a left neck mass. Laboratory results indicated a positive test result for HIV (CD4 = 79 cells/mm3, CD4 T-lymphocyte percentage 3%). According to state reporting, the patient had received a positive HIV test result in 2020 but was subsequently lost to follow-up. A computed tomography scan of his neck identified a 6.9 x 7.7 x 9.8–cm mass and extensive bilateral cervical lymphadenopathy. On hospital day 2, the patient became somnolent and was transferred to ICU; the next day, he was intubated for airway protection and received intravenous tecovirimat. He developed vasopressor-resistant hypotension, experienced a seizure, and went into kidney failure. During the next several days he was treated with vasopressors, antiepileptics, antibiotics, and antifungals, and required cardiopulmonary resuscitation. An extensive evaluation for infectious agents other than OPXV and HIV was negative. On the second day in ICU, he received 1 dose of VIGIV. Two days later, a brain scan indicated poor perfusion. The family elected to transition the patient to comfort measures. He was terminally extubated. An autopsy was conducted, with pathologic findings of necrosis in multiple tissues consistent with diffuse monkeypox. Immunohistochemistry testing demonstrated extensive orthopoxviral antigen in multiple tissues. Cytomegalovirus antigen was also detected in some tissues.¶¶¶
Patient B. In July 2022, a Black man in his 30s with AIDS (CD4 <10 cells/mm3) and not receiving ART developed a rash on his face, head, back, and genitals. At multiple subsequent clinic visits, he was tested and treated for gonorrhea, chlamydia, and syphilis; however, his genital lesions progressed, and he experienced phimosis and urinary retention for which he was admitted to a hospital 4 weeks after his rash began. A lesion swab taken the day of admission tested positive for Monkeypox virus (MPXV) DNA by PCR. The patient was discharged with a urinary catheter and 14 days of oral tecovirimat (Supplementary Figure 1; https://stacks.cdc.gov/view/cdc/121838. His skin lesions initially improved, but then spread, coalesced, and developed central necrosis (Figure) (Supplementary Figure 2, https://stacks.cdc.gov/view/cdc/121835). A suprapubic catheter was placed because of continued need for urinary catheterization. Approximately 10 days after discharge, the patient was readmitted with malaise, poor appetite, weight loss, and new hand and penile lesions. During a 15-day hospitalization, the patient was found to have methicillin-resistant Staphylococcus aureus bacteremia. He was transferred to ICU because of atrial fibrillation with rapid ventricular response. In ICU he was treated with intravenous tecovirimat, 2 doses of VIGIV, and antimicrobials. Conjunctivitis developed and was treated with trifluridine and antibacterial eye drops. The patient was discharged on oral tecovirimat and ART and with a suprapubic catheter. During week 7 of oral tecovirimat, he was readmitted because of progressive necrotic lesions with bacterial superinfection on the left hand, left eyelid lesions with periorbital swelling, and a right ear canal lesion associated with drainage and decreased hearing. He was restarted on intravenous tecovirimat and continues this treatment as of this report.
Patient C. In July 2022, a non-Hispanic White man in his 40s with AIDS (CD4 <10 cells/mm3) and not receiving ART was evaluated for a rash on his face, torso, hands, feet, and perianal area; lesion swabs tested positive for MPXV DNA by PCR. He was admitted to a hospital for pain control and received oral tecovirimat and ART. The patient experienced pain relief and was discharged after 7 days to complete 14 days of tecovirimat. However, his housing and food situations were unstable, and absorption of oral tecovirimat is dependent on concurrent intake of a full, fatty meal. Approximately 3 weeks after discharge, he was readmitted with coalescing, painful, and necrotic lesions on his hands and feet. Despite treatment with oral and intravenous tecovirimat for >4 weeks, 2 doses of cidofovir, 1 dose of VIGIV, and multiple antibiotics, progressive tissue necrosis led to debridement of the soft tissues of the right index finger and amputation of the right fourth toe. Gradually, the monkeypox lesions regressed. He was discharged but was readmitted 1 week later for unresolved lesions and severe pain. He received a second dose of VIGIV and remains hospitalized on oral tecovirimat and ART as of this report.