Examining 2 Mpox Cases

In a letter to the editor in the New England Journal of Medicine that appeared in this evening’s edition online, members of the CDC, Los Angeles County Department of Public Health, and other LA-area health officials discussed a fatal mpox case.

The patient was described as a 33-year-old man with HIV who was recently treated for syphilis and became infected with mpox. According to the health officials, the patient reported he had not received a vaccine for orthopoxvirus and did not have a known exposure to persons with mpox.

Treatment
The patient was diagnosed with mpox on day 15 of his illness and was given oral tecovirimat 6 days later. He was admitted to the hospital for severe mpox, dehydration, and difficulty with swallowing oral medication on day 25. While in the hospital, the patient received intravenous fluids, pain medication, a second course of oral tecovirimat, and broad-spectrum antibiotic agents.

Health officials report the patient had severe proctitis that led to large-bowel obstruction, sepsis, anasarca, and an exudative pleural effusion on the right side. The patient developed hypoxic respiratory failure, septic shock, and renal failure on his 25th day in the hospital. He was transitioned to comfort care and died in the hospital two days later.

The health officials offered some considerations for any clinicians treating patients with severe mpox. “In hospitalized patients with severe mpox, it is important to consider treatment with intravenous tecovirimat. Second-line therapies including cidofovir, brincidofovir, and vaccinia immune globulin may also be considered. If progressive or persistent lesions are present after 14 days of treatment with tecovirimat, pharmacokinetic testing of tecovirimat and testing of lesion specimens for antiviral resistance are warranted,” they wrote.

They also said that for mpox patients who also have HIV, they should be closely monitored to reduce the risk of progressing to a more severe form of the novel virus.

Case of Non–Needle Stick Mpox Transmission of Healthcare Worker

The following is a case reported in CDC's Emerging Infectious Diseases publication.

Although extremely rare, this case represents outlier events. This case also occurred in Los Angeles County and the patient was described as a 40-year-old woman who is a physician. The CDC, Los Angeles County Department of Public Health, and other LA-area health officials reported this case.

In August 2022, a physician experienced a prodrome of myalgia and fatigue, followed by a mild headache. According to the report, she noticed a small, raised skin lesion on her left middle finger 2 days later. The skin lesion progressed to a blister and developed umbilication; it grew to 1.5–2 cm, and a swab sample for mpox was collected on day 6 of illness. On days 9 and 10 after symptom onset, the physician experienced fever for 48 hours, followed by a cough and sore throat. A total of 10 skin lesions developed throughout her body. The physician received a 2-week course of oral tecovirimat, experienced no complications, and completely recovered.

The physician works at two clinics that serve LGBTQ+ and HIV-positive patient populations. She has reported to regularly seeing patients with mpox, during which she wears full personal protective equipment (PPE) that includes a N95 respirator, a gown, and eye protection.

During the presumed incubation period, the physician interacted with 2 patients (patients A and B) who did not undergo triage per clinic protocols for suspected infection with mpox, but according to the physician, had symptoms concerning infection.

The physician saw patient A 29 days before her own symptom onset. She spent 15 minutes with the patient while wearing a surgical mask and gloves. When the patient disclosed symptoms concerning mpox, the physician left the examination room and donned PPE before swabbing the patient’s lesions. Samples from patient A tested positive for mpox. The physician saw patient B 4 days before her symptom onset. She spent 5 minutes with the patient while wearing a surgical mask and gloves. When the patient disclosed mpox symptoms, the physician left the room and donned PPE before swabbing the patient’s lesions. Samples from patient B tested positive for mpox.

“Although the risk to HCWs in the United States continues to be very low, it is crucial to continue public health outreach, infection prevention, and training of HCWs to prevent MPXV transmission in healthcare settings, especially during specimen collection,” the health officials wrote.