Leah Safe, MD1,2; Elizabeth Garcia, PharmD2; Tristan D. McPherson, MD2; Maura Rush, MPH2; Karen A. Alloy, DVM2;Mary Hoot, M.D.2; Ellen H. Lee, M.D.2; Jeffrey Kwon, DNP3Asa Radix, MD, PhDFour; Paul Liska, M.D.Five; Jason Zucker, MD6Sarah Zuercher, MS, MSN7; Marsha Wong, M.D.2 (Show author affiliation)
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monkeypox virus Orthopoxviruses can cause substantial morbidity due to lesions of the skin and mucous membranes (1). During the 2022 multinational monkeypox (mpox) epidemic, tecovirimat, an antiviral drug approved for the treatment of smallpox, was used as an investigational drug for his severe mpox. However, efficacy and optimal duration of treatment are still under investigation (1,2). An evaluation of the use of tecovirimato for the treatment of mpox under the Extended Access Investigational New Drug Protocol in late 2022 found that three patients developed new lesions after completing treatment (3). This report describes a series of mpox patients in New York City (NYC) who also developed new lesions after completion of tecovirimato treatment, suggesting that posttreatment lesions may be more common than previously reported. It has been suggested that there is
A case of post-treatment mpox lesion was defined as the development of a new skin or mucosal lesion in a New York City resident with probable or confirmed mpox (Four), appearing within 30 days of completing the recommended 14-day course of tecovirimat treatment and after resolution or resolution of the initial mpox lesion. From August 2022 to September 2022, a healthcare provider voluntarily reported 10 such cases to her to the New York City Department of Health and Mental Hygiene (DOHMH). Providers were asked to complete a survey detailing patient demographics, clinical characteristics, and disease course. A descriptive analysis was performed on nine of her surveys submitted.
The median patient age was 33 years (range = 23–46 years). Eight were male and one was a transgender female (table). Of her eight patients whose race was reported, four were black or African American and four were white. Two patients reported Hispanic or Latino ethnicity. HIV status was known in all 9 of her patients. Five of her were HIV-infected (CD4 count >350 cells/mm3 and viral load <200 copies/mL), and those not taking antiretroviral drugs (CD4 count <200 cells/mm3 and viral load unknown).
No patient received the JYNNEOS vaccine* prior to experiencing mpox.first lesion was positive orthopox virus Use the polymerase chain reaction test. The median initial symptom severity score was 8 out of 23 possible points (range = 6–13) and was assessed using the mpox severity score.†Six patients were tested for sexually transmitted infections (STIs) at the time of diagnosis of mpox. One tested positive for gonorrhea and was treated.§
The median interval from onset of mpox symptoms to onset of tecovirimat was 9 days (range = 6–16 days). All patients received outpatient care from their health care provider with weight-appropriate oral doses of tecovirimato and completed her recommended 14-day course with self-reported complete adherence. None of the patients reported adverse reactions, and the provider assessed that her mpox lesions in all patients had improved after completing treatment.
New lesions appeared a median of 13 days (range = 2–30 days) after completion of tecovirimato treatment. In 8 patients, post-treatment lesions were rated by providers as less severe than initial lesions (median severity score = 3 [range = 3–7]). Of the six patients in whom post-treatment lesional orthopoxvirus testing was performed, one received a positive result. Two patients underwent her STI examination repeatedly. One had a positive test result for syphilis. Treatment-naïve HIV-infected, immunocompromised patients tested positive for both orthopoxvirus and syphilis after treatment.¶ Tecovirimat was restarted in two patients (one with an additional 7 days of treatment and the other with an additional 14 days of treatment), both with disease resolution. Of her 7 patients who did not receive her course of tecovarimato, 6 had disease resolution and 1 was lost to follow-up.
The findings of this report have at least three limitations. First, the number of cases reported here may underestimate the true prevalence, as no active surveillance for post-treatment lesions has been performed.Second, not all post-treatment lesions were examined orthopox virus or other potential etiology. Finally, the analysis relied on provider-reported data, which can be subjective.
Further studies are needed to understand the etiology of new lesions in mpox patients after completion of tecovarimato therapy. One possibility is monkeypox viruslike other viruses (e.g. SARS-CoV-2), can recur (Five), but the repeat viral load may be too low for test detection. Most of the post-treatment lesions in this analysis resolved without further treatment, suggesting that immunocompetent patients may not require additional tecovirimato. However, the clinical course of immunocompromised patients can be more complex. The proportion of patients not tested for STIs at initial mpox diagnosis and post-treatment lesion assessment represents a missed opportunity to identify potential co-infections or alternative diagnoses.
1Office of Epidemic Information, CDC; 2New York City Department of Health and Mental Health, New York, NY; 3Gotham Medical Group, New York, NY. FourCallen-Lorde Community Health Center, New York, NY; FiveMontefiore Medical Center, New York, NY. 6New York Presbyterian Hospital, Columbia University, New York, NY. 7AIDS Healthcare Foundation Healthcare Center, New York, NY.
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