Mpox in advanced AIDS with concurrent opportunistic infections: periprocedural management challenges

Mpox can be severe and prolonged in people with advanced human immunodeficiency virus. Concurrent opportunistic infections and diagnostic uncertainty may delay definitive therapy and complicate infection control and procedural planning.

A 42-year-old man with long-standing acquired immunodeficiency syndrome (AIDS) and inconsistent antiretroviral adherence presented with fever, cough, diffuse lymphadenopathy, and multiple papules on the skin, some being violaceous and crusted and others epithelialized. Imaging showed diffuse lymphadenopathy and pulmonary nodules. Broad differential diagnoses included disseminated coccidiomycosis, Pneumocystis pneumonia, Kaposi sarcoma, human herpesvirus 8-associated disease, and mpox. Cell-free DNA next-generation sequencing demonstrated mpox clade II and concurrent pathogens. Tecovirimat was obtained under the Centers for Disease Control and Prevention (CDC) expanded-access protocol and administered for 14 days with epithelialization of skin lesions, suggesting resolution of mpox except for persistent mpox polymerase chain reaction positivity of one epithelialized lesion.Our team deferred inpatient lymph node biopsy because neither the CDC nor World Health Organization guidelines provide specific periprocedural isolation workflows (e.g. procedure room selection, anaesthesia considerations, staff personal protective equipment beyond standard recommendations, and postprocedure decontamination) for mpox patients, and we found no state, national, or international guidelines addressing periprocedural isolation precautions for mpox.

This case highlights the management complexity of mpox in advanced AIDS with multiple concurrent opportunistic infections. It also underscores operational gaps for time-sensitive procedures in patients requiring mpox isolation precautions, emphasizing the need for practical periprocedural guidance and evolving CDC recommendations.