Clinical presentation of Monkeypox among people living with HIV in South Florida: a case series.

Introduction: Monkeypox, historically a zoonotic disease caused by monkeypox virus, is a new global health emergency. Since May 2022, dozens of non-endemic countries have seen new cases with rapid spread. Generally a self-limited disease, there are vulnerable populations, in which severe or deadly illness can occur. There is limited data on immunocompromised patients in this outbreak, particularly on people living with HIV, who are disproportionately affected.

Methods: We reported seven cases of monkeypox in people living with HIV in South Florida, USA. Relevant demographic, epidemiologic and clinical data were described.

Results: All the patients were men, identified as gay or bisexual, and were on combination antiretroviral therapy (cART) for HIV. Six of the seven had CD4 counts more than 200 cells/mm³ (one unknown level), and one of the seven had detectable HIV viral load. Six had sexual or intimate contact with asymptomatic partners prior to development of symptoms. Two were hospitalized, one for proctitis and one for an increasing number of lesions. Six had disseminated lesions and one had localized perianal lesions and all had 5-25 total number of lesions. Five received tecovirimat with resolution of lesions in 2-14 days and all were doing well at the time of the present report. Close contacts received the Jynneos vaccine which was well tolerated.

Conclusions: Our case series described monkeypox in people living with HIV and have noted atypical symptoms (lack of fever and more notable anogenital lesions) and relatively mild course as described in HIV seronegative patients. We stress the importance of early detection and isolation as well as vaccination to contacts, which has been well tolerated. In our case series, we are unable to estimate the effectiveness of tecovirimat given the limited number of patients, but all our patients had lesions that resolved within two weeks of rash onset and had no side effects reported.