Posted Oct. 4, 2022. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.
SRHD Reminders
- Several “indeterminate” monkeypox results have occurred, which may be due to improper sample collection. Please ensure that specimen collection for Monkeypox testing is adequate:
CDC HAN Summary
SRHD is sharing this Centers for Disease Control and Prevention (CDC) Health Alert Network (HAN) Health Advisory to inform healthcare providers that
- Severe manifestations of monkeypox have been observed in the United States in the current outbreak.
- People who are immunocompromised due to HIV or other conditions are at higher risk for severe manifestations of monkeypox than people who are immunocompetent.
- Because people with HIV-associated immunocompromise are at risk for severe manifestations of monkeypox, the HIV status of all sexually active adults and adolescents with suspected or confirmed monkeypox should be determined.
- There are diagnostic and clinical management strategies that may help address severe manifestations of monkeypox.
Background
Since May 2022, more than 25,000 monkeypox cases have been identified in the United States. During the current outbreak in the United States, 38 percent of people diagnosed with monkeypox were coinfected with HIV and most reported cases of monkeypox with severe manifestations have been among people living with untreated HIV.
Some patients with monkeypox in the United States have experienced prolonged hospitalizations or substantial morbidity; deaths have occurred. As the monkeypox outbreak has progressed, an increasing proportion of cases have been identified among Black and Hispanic/Latino people. Black and Hispanic/Latino people are disproportionately affected by HIV.
Severe manifestations of monkeypox can occur in both immunocompetent and immunocompromised people; however, most people diagnosed with monkeypox have had mild-to-moderate clinical courses. Of the people with severe manifestations of monkeypox for whom CDC has been consulted, the majority have had HIV with CD4 counts <200 cells/ml, indicating substantial immunosuppression. Healthcare providers should recognize underlying risk factors for severe disease, optimize immune function, and when appropriate, initiate medical countermeasures (such as tecovirimat and vaccinia immunoglobulin) early to prevent or mitigate severe disease.
During the current outbreak, CDC has received reports of people with monkeypox who have severe manifestations of disease, including but not limited to
- Atypical or persistent rash with coalescing or necrotic lesions, or both, some which have required extensive surgical debridement or amputation of an affected extremity.
- Lesions on a significant proportion of the total body surface area, which may be associated with edema and secondary bacterial or fungal infections among other complications.
- Lesions in sensitive areas (including mucosal surfaces such as, oropharynx, urethra, rectum, vagina) resulting in severe pain that interferes with activities of daily living.
- Bowel lesions that are exudative or cause significant tissue edema, leading to obstruction.
- Severe lymphadenopathy that can be necrotizing or obstructing (such as in airways).
- Lesions leading to stricture and scar formation resulting in significant morbidity such as urethral and bowel strictures, phimosis, and facial scarring.
- Involvement of multiple organ systems and associated comorbidities, including:
- Oropharyngeal lesions inhibiting oral intake
- Pulmonary involvement with nodular lesions
- Neurologic conditions including encephalitis and transverse myelitis
- Cardiac complications including myocarditis and pericardial disease
- Ocular conditions including severe conjunctivitis and sight-threatening corneal ulcerations
- Urologic involvement including urethritis and penile necrosis
Recommendations for Healthcare Providers
- Upon initial presentation of signs and symptoms consistent with monkeypox, in addition to monkeypox, test all sexually active adults and adolescents for HIV (including acute infection) and other sexually transmitted infections (such as syphilis, herpes, gonorrhea, and chlamydia), and assess for other immunocompromising conditions.
- Be familiar with severe manifestations of monkeypox and risk factors for severe disease.
- Contact SRHD Epidemiology early when there is concern for progression to severe manifestations or severe manifestations are present for guidance on management and securing necessary resources for treatment.
- Email cdepidutyofficer@srhd.org using encrypted/secure email or call 509.324.1442 during business hours. Please use 509.869.3133 after hours. You may also send notifications via fax at 509.324.3623.
- Consider treating immunocompromised people diagnosed with monkeypox with tecovirimat early in the course of disease and consider a prolonged course of tecovirimat for those with more refractory and severe monkeypox infection. In certain clinical situations, modifications to the dose, frequency, and duration may be necessary depending on the individual’s clinical condition, disease progression, therapeutic response, and clinical judgement in consultation with CDC and FDA as appropriate.
- Where available, healthcare providers should encourage people with monkeypox to be assessed for enrollment in the ACTG STOMP trial evaluating the efficacy of tecovirimat.
- Have a low threshold to use multiple medical countermeasures, including tecovirimat, cidofovir or brincidofovir, and VIGIV in immunocompromised people who present with severe manifestations of monkeypox or are at high risk of progression to severe manifestations.
- Optimize immune function among immunocompromised people with suspected or confirmed monkeypox, specifically by ensuring those with HIV are on effective antiretroviral therapy.
- Discuss HIV pre-exposure prophylaxis (PrEP) with those who are HIV negative and at risk for HIV.
- Contact SRHD’s PrEP Coordinator at 509.324.1438 or PrEP@srhd.org for more information
View the full CDC Health Advisory here: Severe Manifestations of Monkeypox among People who are Immunocompromised Due to HIV or Other Conditions (cdc.gov)
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