(P206) Severe Mpox in the Setting of Advanced HIV: Case Review and Lessons Learned

Project: We describe our experience in treating two patients with advanced HIV with severe mpox during the 2022 mpox outbreak.

Issue: There are a limited number of treatment options for the management of mpox and the optimal treatment strategy for severe disease is yet to be determined.

Results: Two patients with advanced HIV (CD4 count 58 and 9.9 cells/mm³ in each case respectively) and severe mpox (with disseminated lesions and organ dysfunction) requiring inpatient management presented to our medical center in September and October 2022. In both cases, intravenous tecovirimat was initiated and vaccinia immune-globulin (VIGIV) was administered at 5 days and 1 month into therapy in each case respectively. VIGIV was redosed only once more in both cases with the second doses given 6 and 10 days later in each case. One of the patients also received intravenous cidofovir on day 5 and 21 of therapy, while the other did not due to poor renal function. Despite the implemented therapeutic measures, both patients unfortunately expired.

Lessons Learned: Despite the poor outcomes observed in the two patients described, there are several important lessons learned from our management of these patients. The first, in the setting of severe disease, it may be pertinent to consider additional therapies (VIGIV, cidofovir, brincidofovir) to tecovirimat early on. In both cases, additional therapy was not added until several days if not weeks after starting therapy with tecovirimat. Second, in both cases, it appeared 14 days of tecovirimat was not an adequate duration and the CDC recommended continuing therapy until clinical improvement was observed, in one of the cases therapy was stopped at 14 days before these recommendations from the CDC were available. Third, optimizing immune function is imperative for recovery from mpox, which can be achieved by ensuring that patients are on effective anti-retroviral therapy and avoidance of immunosuppressive therapies if possible. Fourth, providers should promptly look to discuss all cases of severe disease with the CDC and their city/state health departments to discuss and request available therapies for mpox to facilitate timely initiation of treatment.