Introduction
Mpox virus (MPXV) is a large double-stranded DNA virus that causes a
febrile illness with rash in humans. Until recently, MPXV caused
sporadic zoonotic outbreaks primarily in Africa. However, in May 2022, a
cluster of non-travel-related cases of human mpox were reported in the
United Kingdom. Since those initial infections, the outbreak has spread
world-wide infecting over 85,000 patients and causing over 100 deaths.
Early outbreak data suggested no significant difference in outcome among
people living with Human Immunodeficiency Virus (PLWH, HIV) and those
without HIV. However, subsequent data have shown the majority of severe
and fatal cases of human mpox infection occur in those with advanced
HIV. It is now clear that advanced HIV is a significant risk factor for
severe mpox and death, and that Immune Reconstitution Inflammatory
Syndrome (IRIS) may play a role in these outcomes.
While the number of new mpox cases has dropped significantly since the
outbreak began, recent case clusters suggest ongoing community
transmission. This continued circulation poses an ongoing threat to
susceptible hosts. Risk factors for progression of disease other than
advanced HIV, natural progression of disease, and optimal management
remain undefined. While the STOMP Trial and VIRISMAP are actively
enrolling patients to address these questions, the decline in cases
worldwide (a positive development overall) has stymied hopes of rapid
answers. Given the rare occurrence of this infection in the outbreak’s
current phase, and the absence of clinical trial data to address
treatment for the most severe cases, optimal management will require
vigilant multidisciplinary collaboration between the specialties
involved in the care of these patients. This review summarizes the
pathogenesis of mpox, available clinical data, identifies knowledge gaps
and proposes recommendations on the management of these most severe
cases among patients with advanced HIV with an emphasis on early
combination antivirals and longitudinal wound care.