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Mpox, formerly known as monkeypox, has re‐emerged as a significant global health concern, particularly during the widespread outbreak of 2022. As an orthopoxvirus related to the eradicated smallpox virus, mpox has been primarily managed with smallpox vaccines and treatments, including the antiviral agent Tecovirimat. This systematic review aims to evaluate the effectiveness and safety of Tecovirimat in treating mpox, focusing on its use during the 2022 outbreak, especially among high‐risk populations, including men who have sex with men and people living with HIV. We conducted a comprehensive search across databases, such as Embase, PubMed, and Web of Science, up to August 30, 2024. The selection involved a two‐stage review process utilizing the Nested Knowledge platform, which helped streamline the screening and data extraction. We included studies that focused on the clinical efficacy and safety of Tecovirimat in human patients with confirmed mpox infections. Our analysis mainly synthesized data narratively due to the heterogeneity of study designs and outcomes. Fifteen studies met the inclusion criteria, providing data on 1031 mpox cases. The preliminary analysis of the PALM 007 RCT indicated that tecovirimat did not significantly outperform placebo in lesion resolution for all patients. Lesions healed faster than expected, regardless of tecovirimat or placebo treatment. A lower mortality rate of 1.7% among those enrolled in the PALM 007 RCT was observed, compared to the general mpox mortality rate of 3.6% or higher in the DRC. Observational studies revealed that early administration of Tecovirimat, especially within the first week of symptom onset, significantly improves symptom resolution, reduces the severity of the disease, and decreases the likelihood of hospitalization and complications in observational studies. However, the impact on viral clearance was inconsistent, and some studies suggested limited efficacy in severely immunocompromised patients. Regarding safety, Tecovirimat was generally well‐tolerated as indicated by the RCT; however, mild adverse effects such as fatigue, headache, and nausea were commonly reported among observational studies. Serious adverse events were rare but included elevated liver enzymes and psychiatric symptoms, particularly in patients with pre‐existing conditions. Tecovirimat demonstrates some potential benefits in treating mpox, particularly when administered early. The PALM 007 RCT failed to meet the efficacy point. Tecovirimat is generally well‐tolerated with a favorable safety profile, although monitoring is advisable for those with existing liver or renal conditions. Despite promising results, further large‐scale randomized controlled trials are needed to fully ascertain the drug's effectiveness across diverse populations and to explore its impact on viral clearance and transmission dynamics.
Mpox, formerly known as monkeypox, has re‐emerged as a significant global health concern, particularly during the widespread outbreak of 2022. As an orthopoxvirus related to the eradicated smallpox virus, mpox has been primarily managed with smallpox vaccines and treatments, including the antiviral agent Tecovirimat. This systematic review aims to evaluate the effectiveness and safety of Tecovirimat in treating mpox, focusing on its use during the 2022 outbreak, especially among high‐risk populations, including men who have sex with men and people living with HIV. We conducted a comprehensive search across databases, such as Embase, PubMed, and Web of Science, up to August 30, 2024. The selection involved a two‐stage review process utilizing the Nested Knowledge platform, which helped streamline the screening and data extraction. We included studies that focused on the clinical efficacy and safety of Tecovirimat in human patients with confirmed mpox infections. Our analysis mainly synthesized data narratively due to the heterogeneity of study designs and outcomes. Fifteen studies met the inclusion criteria, providing data on 1031 mpox cases. The preliminary analysis of the PALM 007 RCT indicated that tecovirimat did not significantly outperform placebo in lesion resolution for all patients. Lesions healed faster than expected, regardless of tecovirimat or placebo treatment. A lower mortality rate of 1.7% among those enrolled in the PALM 007 RCT was observed, compared to the general mpox mortality rate of 3.6% or higher in the DRC. Observational studies revealed that early administration of Tecovirimat, especially within the first week of symptom onset, significantly improves symptom resolution, reduces the severity of the disease, and decreases the likelihood of hospitalization and complications in observational studies. However, the impact on viral clearance was inconsistent, and some studies suggested limited efficacy in severely immunocompromised patients. Regarding safety, Tecovirimat was generally well‐tolerated as indicated by the RCT; however, mild adverse effects such as fatigue, headache, and nausea were commonly reported among observational studies. Serious adverse events were rare but included elevated liver enzymes and psychiatric symptoms, particularly in patients with pre‐existing conditions. Tecovirimat demonstrates some potential benefits in treating mpox, particularly when administered early. The PALM 007 RCT failed to meet the efficacy point. Tecovirimat is generally well‐tolerated with a favorable safety profile, although monitoring is advisable for those with existing liver or renal conditions. Despite promising results, further large‐scale randomized controlled trials are needed to fully ascertain the drug's effectiveness across diverse populations and to explore its impact on viral clearance and transmission dynamics.
MPOX virus (MPXV), formerly known as monkeypox virus, led to a rapidly evolving pandemic starting May 2022, with over 90,000 cases reported beyond the African continent. This pandemic outbreak was driven by the MPXV variant Clade IIb. In addition, Clade I viruses circulating in the Democratic Republic of Congo (DRC) are drawing increased attention as cases constantly rise and Clade Ib, first identified in 2023, is now co-circulating with Clade Ia and seems to exhibit enhanced human-to-human transmissibility. While most infected individuals display a self-limiting disease with singular pox-like lesions, some endure systemic viral spread leading to whole-body rash with risks for necrosis, organ loss, and death. Intra-host dissemination and cellular tropism of MPXV are largely unexplored in humans. To establish a potential susceptibility of circulating immune cells to MPXV, we exposed human PBMCs from healthy donors ex vivo to a currently circulating MPXV clade IIb virus isolate in absence and presence of IFN-α2a. qPCR of DNA extracted from cell lysates, but less from supernatants, revealed increasing MPXV DNA quantities that peaked at five to six days post-exposure, suggesting susceptibility of PBMCs to infection. IFN-α2a pretreatment markedly reduced the quantity of MPXV DNA, suggesting that infection is sensitive to type I IFNs. Plaque assays from supernatants showed that infection gave rise to de novo production of infectious MPXV. In virus-inclusive scRNA-sequencing, monocytes, cycling NK cells and regulatory CD4+ T-cells scored positive for viral RNA, suggesting that these are the MPXV-susceptible cell types within the human PBMC population. Analysis of differentially expressed genes displayed a pronounced downregulation of expression pathways driving innate immunity in MPXV-infected cells, a well-established feature of poxviral infection. Pretreatment of PBMCs with current antivirals Cidofovir and Tecovirimat resulted in reduced amounts of viral antigen production and of released infectivity, suggesting suitability of the human PBMC infection model as a platform for evaluation of current and future antivirals and justifying trials to investigate Cidofovir and Tecovirimat as drugs reducing intra-patient viral spread. Together, our data suggest that human PBMCs are productively infected by MPXV which is accompanied by significant modulation of the cellular milieu. Our results have the potential to illuminate aspects of intra-host propagation of MPXV that may involve a lymphohematogenous route for replication and/or intra-host dissemination.
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