PMID- 36992234 OWN - NLM STAT- PubMed-not-MEDLINE LR - 20230401 IS - 2076-393X (Print) IS - 2076-393X (Electronic) IS - 2076-393X (Linking) VI - 11 IP - 3 DP - 2023 Mar 14 TI - Successful Outcome after Treatment with Cidofovir, Vaccinia, and Extended Course of Tecovirimat in a Newly-Diagnosed HIV Patient with Severe Mpox: A Case Report. LID - 10.3390/vaccines11030650 [doi] LID - 650 AB - PURPOSE: To report a case of severe mpox in a newly diagnosed HIV patient concerning for Immune Reconstitution Inflammatory Syndrome (IRIS) and/or tecovirimat resistance and to describe the management approach in the setting of refractory disease. CASE: 49-year-old man presented with 2 weeks of perianal lesions. He tested positive for mpox PCR in the emergency room and was discharged home with quarantine instructions. Three weeks later, the patient returned with disseminated firm, nodular lesions in the face, neck, scalp, mouth, chest, back, legs, arms, and rectum, with worsening pain and purulent drainage from the rectum. The patient reported being on 3 days of tecovirimat treatment, which was prescribed by the Florida department of health (DOH). During this admission, he was found to be HIV positive. A pelvic CT scan revealed a 2.5 cm perirectal abscess. Treatment with tecovirimat was continued for 14 days, along with an empiric course of antibiotics for treatment of possible superimposed bacterial infection upon discharge. He was seen in the outpatient clinic and initiated antiretroviral therapy (ART) with TAF/emtricitabine/bictegravir. Two weeks after starting ART, the patient was readmitted for worsening mpox rash and rectal pain. Urine PCR also returned positive for chlamydia, for which the patient was prescribed doxycycline. He was discharged on a second course of tecovirimat and antibiotic therapy. Ten days later, the patient was readmitted for the second time due to worsening symptoms and blockage of the nasal airway from progressing lesions. At this point, there were concerns for tecovirimat resistance, and after discussion with CDC, tecovirimat was reinitiated for the third time, with the addition of Cidofovir and Vaccinia, and showed an improvement in his symptoms. He received three doses of cidofovir and two doses of Vaccinia, and the patient was then discharged to complete 30 days of tecovirimat. Outpatient follow-up showed favorable outcomes and near resolution. CONCLUSION: We reported a challenging case of worsening mpox after Tecovirimat treatment in the setting of new HIV and ART initiation concerning IRIS vs. Tecovirimat resistance. Clinicians should consider the risk of IRIS and weigh the pros and cons of initiating or delaying ART. In patients not responding to first-line treatment with tecovirimat, resistance testing should be performed, and alternative options should be considered. Future research is needed to establish guidance on the role of Cidofovir and Vaccinia immune globulin and the continuation of tecovirimat for refractory mpox. FAU - Martinez, Andres E AU - Martinez AE AD - Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA. AD - Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA. FAU - Frattaroli, Paola AU - Frattaroli P AD - Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA. AD - Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA. FAU - Vu, Christine A AU - Vu CA AD - Department of Pharmacy, Jackson Memorial Hospital, Miami, FL 33136, USA. FAU - Paniagua, Lizy AU - Paniagua L AD - Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA. AD - Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA. FAU - Mintz, Joel AU - Mintz J AD - Department of Internal Medicine, University of Miami, Jackson Memorial Hospital, Miami, FL 33136, USA. FAU - Bravo-Gonzalez, Andres AU - Bravo-Gonzalez A AD - CES University, Medellin, Antioquia 050007, Colombia. FAU - Zamudio, Paola AU - Zamudio P AUID- ORCID: 0009-0007-0749-4532 AD - Universidad Anahuac Queretaro, Queretaro 76246, Mexico. FAU - Barco, Astrid AU - Barco A AD - Universidad de Especialidades Espiritu Santo, Guayas 092301, Ecuador. FAU - Rampersad, Aruna AU - Rampersad A AD - Couva Hospital and Multi Training Facility, Couva 550214, Trinidad and Tobago. FAU - Lichtenberger, Paola AU - Lichtenberger P AD - Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA. AD - Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA. FAU - Gonzales-Zamora, Jose A AU - Gonzales-Zamora JA AUID- ORCID: 0000-0002-2768-9712 AD - Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA. AD - Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA. AD - Peruvian American Medical Society (PAMS), Albuquerque, NM 87111, USA. LA - eng PT - Case Reports DEP - 20230314 PL - Switzerland TA - Vaccines (Basel) JT - Vaccines JID - 101629355 PMC - PMC10051473 OTO - NOTNLM OT - HIV OT - cidofovir OT - immune reconstitution inflammatory syndrome OT - mpox OT - tecovirimat OT - vaccinia immune globulin COIS- The authors declare no competing conflict of interest. EDAT- 2023/03/31 06:00 MHDA- 2023/03/31 06:01 PMCR- 2023/03/14 CRDT- 2023/03/30 01:05 PHST- 2023/02/28 00:00 [received] PHST- 2023/03/10 00:00 [revised] PHST- 2023/03/13 00:00 [accepted] PHST- 2023/03/31 06:01 [medline] PHST- 2023/03/30 01:05 [entrez] PHST- 2023/03/31 06:00 [pubmed] PHST- 2023/03/14 00:00 [pmc-release] AID - vaccines11030650 [pii] AID - vaccines-11-00650 [pii] AID - 10.3390/vaccines11030650 [doi] PST - epublish SO - Vaccines (Basel). 2023 Mar 14;11(3):650. doi: 10.3390/vaccines11030650.