Abstract

The World Health Organization reported a multi-country outbreak of mpox (formerly monkeypox) in May 2022. Here, we describe the case of an immunocompromised patient with fulminant mpox. A 41-year-old man with a past medical history of HIV/AIDS nonadherent to antiretroviral therapy with HIV viral load 490,000 and absolute CD4 count 10 and chronic hepatitis B infection presented to the hospital after testing positive for monkeypox. He developed oral lesions and numerous pustular umbilicated papules on the face, abdomen, and legs that later progressed to annular bullae with central necrosis. Histologic examination showed diffuse epidermal and dermal necrosis with some areas flanked by diffuse ballooning degeneration of keratinocytes, multinucleated keratinocytes, and squamous dysmaturation. The patient was treated with oral tecovirimat for two weeks with some improvement. He was readmitted two weeks later due to worsening lesions and was treated with IV tecovirimat. He was later transferred to the burn unit for worsening facial edema and extensive skin necrosis of the face, requiring tracheostomy. He was treated with vaccinia immunoglobulin and cidofovir. The patient was given IV steroids for laryngeal edema and concern for immune reconstitution inflammatory syndrome in setting of reinitiating antiretroviral therapy. Despite interventions, the patient succumbed to disease. This severe disseminated form of mpox has been proposed as an AIDS defining illness given the increased severity and mortality the infection poses to patients with HIV immunosuppression, similar to disseminated histoplasmosis and coccidiomycosis.