A plague passing over: Clinical features of the 2022 mpox outbreak in patients of color living with HIV

Abstract

Introduction: Compared with previous geographically localized outbreaks of monkeypox (MPOX), the scale of the 2022 global mpox outbreak has been unprecedented, yet the clinical features of this outbreak remain incompletely characterized.

Methods: We identified patients diagnosed with mpox by polymerase chain reaction (PCR; n = 36) from July to September 2022 at a single, tertiary care institution in the USA. Demographics, clinical presentation, infection course, and histopathologic features were reviewed.

Results and conclusion: Men who have sex with men (89%) and people living with HIV (97%) were disproportionately affected. While fever and chills (56%) were common, some patients (23%) denied any prodromal symptoms. Skin lesions showed a wide range of morphologies, including papules and pustules, and lesions showed localized, not generalized, spread. Erythema was also less appreciable in skin of colour patients (74%). Atypical clinical features and intercurrent skin diseases masked the clinical recognition of several cases, which were ultimately diagnosed by PCR. Biopsies showed viral cytopathic changes consistent with Orthopoxvirus infections. All patients in this case series recovered without complications, although six patients (17%) with severe symptoms were treated with tecovirimat without complication.

Keywords: HIV; dermatology; histopathology; infection control; infectious disease; mpox; orthopoxviruses; poxviridae; skin of colour; tecovirimat; testing.

Figure 1.

MPOX infection presenting with range of lesion morphologies including macules, papules, pustules, and erosions in five male patients. The distribution of lesions was heterogeneous and included additional anogenital (A), trunk (B), arm (C, D), oropharyngeal (D, E), and facial (E) involvement. MPOX infection in skin of color patients (D, E) Each letter represents a distinct patient.

Figure 2.

MPOX mimicking or coincident with other dermatologic conditions. MPOX infection presenting as disseminated papular lesions in an otherwise asymptomatic female patient initially suspected to have molluscum contagiosum (A). MPOX lesions with facial involvement superimposed on papulopustular acne rosacea in a male patient (B). Two male patients (C, D) were diagnosed with new onset syphilis infection at the time of MPOX testing. Patient C presented with painless genital ulcers and hand involvement. Patient E lacked genital involvement and had a MPOX lesion confined to the eyelid skin, initially concerning for potential keratitis. Each letter represents a distinct patient.

Figure 3.

Histopathologic findings in MPOX of various stages. In an early lesion, there is a sparse perivascular lymphocytic infiltrate (A, 100X total magnification). The epidermal changes are minimal. In papular lesions, there usually is onset of edema, with increased number of inflammatory cells, including neutrophils and few eosinophils (B, 100X). Papular lesions may have a lichenoid infiltrate with variable amounts of spongiosis (C, 200X). As lesions progress, they become vesicular (D, 200X) with ballooning degeneration (E, 200X). Pustules, heavy inflammation, and necrosis characterize the papulonecrotic lesions (F, 200X). Viral cytopathic effect in MPOX lesions. Multinucleated (syncytial) keratinocytes are a common finding (G, ex. in middle portion of image, 400X). Often, the cytoplasm of keratinocytes has a “ground-glass” appearance and rare eosinophilic inclusions can be identified (H, 400X).