Clinical features, treatment, and outcomes of mpox in solid organ transplant recipients: A multicenter case series and literature review

Higgins, Eibhlin; Ranganath, Nischal; Mehkri, Omar; Majeed, Aneela; Walker, Jeremey; Spivack, Stephanie; Bhaimia, Eric; Benamu, Esther; Hand, Jonathan; Keswani, Shobhit; Dunn, D. L.; Beam, Elena; Razonable, Raymund R.

doi:10.1016/j.ajt.2023.07.016

Cited by 10 publications

(6 citation statements)

References 18 publications

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“…Five studies stratified Mpox outcomes based on CD4 and or RNA viral load [ 15 , 23 , 25 , 26 , 40 ] (Table 2 ). Furthermore, 24 studies provided data on deaths among Mpox cases and included information on Immunosuppression source [ 11 – 19 , 25 , 31 – 43 , 45 ], as shown in Table 3 .…”

Section: Resultsmentioning

confidence: 99%

“… Yes, 2 out of 3 were suspected with IRIS, with no data on the history of ART in the third case. Yes Ritter, 2024 [ 43 ] USA 20 (+), 2(-) Uncontrolled HIV (CD4 + cell counts < 150 cells/µL in 20 patients) and 2 immunocompromised patients with renal transplant recipients - Yes Duarte-Neto, 2023 [ 13 ] Brazil 2 (+) Uncontrolled HIV (AIDS) - Yes Mohammed, 2023 [ 42 ] USA 1(+) Uncontrolled HIV (AIDS) - Yes SUN, 2023 [ 41 ] - 1(+) Uncontrolled HIV (AIDS) - Yes Higgins, 2023 [ 45 ] USA 1(-) Renal transplant recipient - Yes Note * The patient was suspected of having IRIS based on the findings of the included study, α: a detailed list of pathogens identified is present in Table S5 , IRIS: immune reconstitution inflammatory syndrome, ART: Antiretroviral therapy, VL: viral load, (-): no data …”

Section: Resultsmentioning

confidence: 99%

“…Most of the reported deaths were observed in patients with HIV with CD4 counts below 200 cells/µL. Seven fatal cases occurred in non-HIV immunosuppressed patients: a case for undiagnosed diabetes [ 16 ], five cases for kidney transplant recipients [ 16 , 39 , 43 , 45 ] and a case for a patient with allogeneic stem cell transplantation [ 32 ]. The main severe manifestations that could contribute to mortality were severe sepsis from secondary bacterial infections, respiratory complications such as pulmonary nodules and airway occlusion, and gastrointestinal complications such as severe proctitis, intestinal obstruction, and bleeding rectal ulcers, as shown in Table S5 .…”

Section: Resultsmentioning

confidence: 99%

“…Most fatal events were observed in HIV-positive individuals with CD4 counts below 200 cells/µL. Seven fatal cases occurred in non-HIV immunosuppressed patients: a case for undiagnosed diabetes [ 16 ], five cases for kidney transplant recipients [ 16 , 39 , 43 , 45 ], and a case for a patient with allogeneic stem cell transplantation [ 32 ]. These findings suggest the importance of expanding treatment considerations for individuals with immunosuppression, regardless of their HIV status.…”

Section: Discussionmentioning

confidence: 99%

“…The CDC also mentioned that it is currently uncertain whether the evidence can be generalized to Mpox [ 51 ]. However, fatal cases of the current 2022 Mpox outbreak were documented in non-HIV immunosuppressed individuals [ 16 , 32 , 39 , 43 , 45 ], providing support for the special risk of severe manifestation of Mpox in those individuals.…”

Section: Discussionmentioning

confidence: 99%

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The impact of immunosuppression on the mortality and hospitalization of Monkeypox: a systematic review and meta-analysis of the 2022 outbreak

Azzam,

Khaled,

Salem

et al. 2024

Virol J

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Background Limited data is available regarding the severity and mortality of Mpox in individuals with immunocompromised conditions. Therefore, we performed this meta-analysis to understand the impact of HIV- or non-HIV-associated immunosuppression on the severity of Mpox requiring hospitalization and mortality. Methods A thorough literature search was performed from 2022 up to January 2024. The results were presented as odds ratios (ORs). We only included patients who required hospitalization for severity rather than isolation. Results A total of 34 studies were included in this analysis. Our analysis did not find a significant difference in the hospitalization risk between HIV-positive individuals and those who were HIV-negative (OR = 1.03; P = 0.85; 7 studies; CD4 count of fewer than 200 cells/µL was less than 0.5% across all studies). Patients with a CD4 count lower than 200 cells/µL or an unsuppressed RNA viral load (> 200 copies/ml) had a significantly higher hospitalization risk (OR = 5.3, P < 0.001) and (OR = 3, P < 0.001), respectively. Most of the reported deaths were reported in patients with HIV with CD4 counts below 200 cells/µL, with some fatal cases occurring in non-HIV immunosuppressed patients, particularly organ transplant recipients. Based on the autopsy findings, Mpox was confirmed in multiple organs, particularly the digestive tract, lung, and testes. Furthermore, some studies documented cases of death that were suspected to be related to hemophagocytic lymphohistiocytosis (HLH) and immune reconstitution inflammatory syndrome (IRIS). Most of the death reports showed concomitant non-Mpox infections at the time of hospitalization and death Conclusions Our finding shows that Mpox acts as an opportunistic pathogen in immunocompromised individuals. These individuals should be prioritized for early care and closely monitored for signs of deteriorating clinical conditions. Clinical manifestations and autopsy findings strongly suggest Mpox dissemination to multiple organs, particularly the digestive tract, and lungs. However, the presence of concomitant non-Mpox infections complicates the assessment of the attribution of Mpox to death. Caution should be exercised when interpreting data suggesting poorer outcomes in individuals with non-HIV immunosuppression, as current evidence is scarce and further research is needed.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

The impact of immunosuppression on the mortality and hospitalization of Monkeypox: a systematic review and meta-analysis of the 2022 outbreak

Azzam,

Khaled,

Salem

et al. 2024

Virol J

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Mpox Clinical Presentation, Diagnostic Approaches, and Treatment Strategies

Titanji,

Hazra,

Zucker

2024

JAMA

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ImportanceA global outbreak of clade IIb Monkeypox virus (MPXV) infections spread rapidly across at least 118 countries resulting in a Public Health Emergency of International Concern (PHEIC) from July 2022 to May 2023. This outbreak affected more than 99 000 persons worldwide and caused more than 33 000 infections and 60 deaths in the US. In 2024, there have been approximately 200 new infections per month in the US. On August 14, 2024, the World Health Organization declared mpox a PHEIC for a second time due to a rapid increase in infections with clade I MPXV in Central Africa.ObservationsMpox is primarily acquired through direct skin to skin contact with MPXV. With clade IIb MPXV, infections are most commonly associated with sexual activity among individuals who are gay, bisexual, and other men who have sex with men. After a median incubation period of 7 to 10 days, prodromal symptoms include fever (62%-72%), lymphadenopathy (56%-86%), myalgias (31%-55%), malaise (23%-57%), and headache (25%-55%). Skin lesions progress through 4 well-defined stages (macules, papules, vesicles, and pustules) over 2 to 4 weeks. Clade IIb MPXV is typically a self-limited illness with a low mortality rate (&lt;0.2% in the US); however, severe illness and death may occur in immunocompromised individuals, especially those with advanced HIV (CD4 count &lt;200 cells/μL). Mpox should be suspected in patients with potential exposure to MPXV who have skin lesions, and the diagnosis is confirmed with polymerase chain reaction testing of lesions. Management is supportive and focuses on skin care and symptom relief with analgesics. While no antiviral treatments are currently approved for mpox by the US Food and Drug Administration, several therapeutics, such as tecovirimat, brincidofovir, and vaccinia immune globulin intravenous, are available through expanded access programs or clinical trials. Vaccination with the 2-dose Modified Vaccinia Ankara-Bavarian Nordic vaccine is recommended for high-incidence populations and has an efficacy of 66% to 86%.Conclusions and RelevanceMpox is a viral infection transmitted primarily through close skin to skin contact that typically causes a self-resolving illness but can result in severe illness and death in immunocompromised individuals. First-line therapy is supportive care, although patients with severe mpox infection may be treated with advanced therapeutics. Mpox vaccination is effective and, if available, should be offered to individuals at risk of exposure to mpox.

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Multiple drugs

2024

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Clinical features, treatment, and outcomes of mpox in solid organ transplant recipients: A multicenter case series and literature review

Cited by 10 publications

References 18 publications

The impact of immunosuppression on the mortality and hospitalization of Monkeypox: a systematic review and meta-analysis of the 2022 outbreak

The impact of immunosuppression on the mortality and hospitalization of Monkeypox: a systematic review and meta-analysis of the 2022 outbreak

Mpox Clinical Presentation, Diagnostic Approaches, and Treatment Strategies

Multiple drugs

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