The Washington PostDemocracy Dies in Darkness

Monkeypox can be far more devastating for patients with weak immune systems

At least 10 patients have died in U.S. outbreak, even as cases continue to fall

Health-care and LGBTQ rights activists protest in August for increased access to monkeypox vaccine and treatments. (Justin Sullivan/Getty Images)
7 min

Monkeypox is causing devastating outcomes for people with severely weakened immune systems, even as new cases continue to decline in the United States, according to a federal report released Wednesday. At least 10 people hospitalized with monkeypox have died.

More than 28,000 cases of monkeypox have been reported since the U.S. outbreak began in May. While the vast majority recover within weeks, some patients with untreated HIV experienced especially dire consequences, such as losing function of their brain or spinal cord, eyes and lungs despite being given antiviral medication.

The report by the Centers for Disease Control and Prevention is based on the agency’s consultations with clinicians treating 57 U.S. patients hospitalized with monkeypox complications from the outbreak’s peak in mid-August through Oct. 10. It presents the most comprehensive picture of the severe consequences of infection and who is most at risk for serious complications.

Should I still be worried about monkeypox?

All 57 patients had severe lesions that could result in dying skin, including 39 people with lesions in their eyes, mouth and other mucous membranes. Two people were undergoing chemotherapy; three had had organ transplants. Nearly a third ended up in intensive care.

Most of the hospitalized patients were Black. All but three were men. Three were pregnant. Nearly a quarter were homeless. The median age was 34.

The CDC does not report hospitalization data, but previous research suggests that between 5 and 10 percent of monkeypox patients are admitted, and those with HIV are more likely to be hospitalized.

Five men share what it’s like to have monkeypox

The report highlighted three representative cases:

· A Latino man in his 20s went to the emergency department in August for back pain and a rash. He tested positive for monkeypox, and his condition quickly worsened. Over the next week, the rash spread to his entire body, he had difficulty breathing and he was admitted to a hospital. He tested positive for HIV; records show he had previously tested positive in 2020 but was lost to follow-up, the report said. Within days, he was transferred to the intensive care unit and given TPoxx and HIV treatment. But his condition worsened. He had a seizure, developed kidney failure and died within a few days.

· A Black man in his 30s with AIDS, who was not receiving treatment, developed a rash on his face, head, back and genitals in July. He was tested and treated for gonorrhea, chlamydia and syphilis. But his genital lesions worsened. Admitted to a hospital four weeks later, he tested positive for monkeypox and was discharged with a two-week supply of TPoxx. His skin lesions initially improved but then worsened, putting him back in the hospital with new lesions on his hand and penis. He developed an antibiotic-resistant bacterial infection, was transferred to the ICU, received intravenous TPoxx and was discharged with oral TPoxx and HIV treatment. During his seventh week on oral TPoxx, he was readmitted to the hospital for worsening destructive lesions with a bacterial superinfection on one hand, left eyelid lesions and a lesion in his right ear linked to decreased hearing. He was restarted on intravenous TPoxx and remained on the treatment.

· A White man in his 40s with AIDS and not receiving treatment was admitted to a hospital in August for a monkeypox-compatible rash. He received oral TPoxx and HIV treatment and was discharged after a week. His food and housing situations were unstable, the report said. Three weeks after he was discharged, he was readmitted with painful and destructive lesions on his hands and feet. Despite multiple treatments, including TPoxx and multiple antibiotics, clinicians had to amputate a toe and part of his right index finger. He was discharged but readmitted one week later for more lesions and severe pain. He remained hospitalized.

Inside America’s monkeypox crisis — and the mistakes that made it worse

“This is an important description of severe consequences of monkeypox and should highlight the critical importance of getting vaccines, treatment and risk messaging to the communities who are most severely impacted,” said Anne Rimoin, an epidemiologist at UCLA who has studied monkeypox in Africa for two decades. “The disproportionate impact on communities that have less access to health services is the same story we see repeating itself locally and globally.”

The outbreak has overwhelmingly affected men who have sex with men. Although monkeypox infections are rarely fatal, many patients experience excruciating pain from lesions and body aches. People of color and those with HIV make up a disproportionate share of patients with the most severe outcomes.

Data about severe complications of the disease show up as an outbreak progresses. People who get sick at the start of an outbreak tend to have more-typical manifestations of disease. But as more people fall ill, more-dire consequences appear. Some monkeypox patients who were sick for many weeks are now dying, officials said.

Monkeypox was the cause of death in three of the 10 cases; seven other deaths are still under investigation, the report said.

Inside a city’s struggle to vaccinate gay Black men for monkeypox

The CDC calls on clinicians to test all sexually active patients with suspected monkeypox for HIV when they test for monkeypox. Clinicians should also consider early monkeypox treatment for all “highly immunocompromised” patients, especially those with advanced HIV disease.

Various surveys have found a significant share of monkeypox patients also have HIV. A national review of nearly 2,000 cases over the summer found that 38 percent had HIV, but the diagnosis alone is not linked to severe outcomes, researchers say.

“While we know HIV impacts our immune system, we also know that not all people with HIV are the same,” said Anu Hazra, co-medical director at Howard Brown Health, a Chicago LGBTQ health provider. HIV patients in successful treatment do not appear to be at increased risk for severe disease, hospitalization or death from monkeypox, he said.

Struggle to protect gay, bisexual men from monkeypox exposes inequities

The growth rate of the U.S. outbreak is slowing, the latest data shows. There have been a few cases of spread to household and nonsexual contacts, but the potential for sustained transmission among heterosexual networks is probably low, according to the CDC.

Daily cases will most likely continue to fall or plateau over the next two to four weeks, but the CDC does not expect domestic transmission to be eliminated in the near future. The outbreak could even accelerate and affect increasingly wider communities if the virus spreads more readily than expected outside networks of men who have sex with men. The virus could get established in an animal host; several animal species in North America may be susceptible to monkeypox and able to transmit the virus to other animals or species.

Health officials and clinicians attribute the decline to vaccination and changes in behavior.

CDC officials are evaluating safety and effectiveness data for the two-dose Jynneos vaccine, the primary vaccine being used in the U.S. outbreak. In early August, federal health officials announced a new strategy to split monkeypox vaccine doses in hopes of vaccinating up to five times as many people against the virus. The alternative method, known as intradermal vaccination, allows a single-use vial to be split into five injections because of the vaccine shortage.

CDC officials are weighing what method should be used for vaccine administration in the long term.