At this time, it is unknown whether a person with severe monkeypox will benefit from treatment with VIGIV, cidofovir, or brincidofovir because effectiveness data are not available. VIGIV is available from the SNS and is administered under an EA-IND protocol for monkeypox. Cidofovir and brincidofovir have proven activity against poxviruses in in vitro and animal studies, but only cidofovir is currently available either commercially or from the SNS. Other treatments that can be considered in severe cases include vaccinia immune globulin intravenous (VIGIV), cidofovir, and brincidofovir. Tecovirimat is available from the Strategic National Stockpile (SNS) and is administered under an expanded access (i.e., compassionate use) Investigational New Drug (EA-IND) protocol held by CDC. Randomized controlled trials in humans are underway to further assess safety as well as efficacy in treating monkeypox. Human clinical trials indicate that the drug is safe and tolerable with only minor side effects ( 14). Data are not available on the effectiveness of tecovirimat in treating monkeypox in humans however, a case report from the United Kingdom suggested that tecovirimat might shorten the duration of illness and of viral shedding ( 13). Animal studies have shown that tecovirimat is effective in treating orthopoxvirus-induced disease ( 12). Tecovirimat is an antiviral medication available in oral and intravenous formulations. However, drugs that are approved for treatment of smallpox and cytomegalovirus might have activity against Monkeypox virus. Treatment: There are no Food and Drug Administration (FDA)–approved treatments for monkeypox. Oropharyngeal symptoms, including symptoms resulting from tonsillitis and epiglottitis, can be associated with pain or difficulty swallowing. Genital and perianal lesions can be associated with severe and painful proctitis, urethritis, phimosis, and balanitis. Mucosal involvement occurs in approximately 40% of cases, including genital, perianal, and oropharyngeal lesions ( 5). Prodrome or systemic symptoms do not always occur or precede the rash. Although any person can acquire monkeypox, epidemiologic data indicate that transmission is currently most intense among interconnected networks of sexually active MSM, with transmission occurring primarily through intimate skin-to-skin contact during sex ( 6). Reports from the current outbreak suggest transmission patterns and clinical manifestations might not follow the classic presentation of monkeypox ( 5– 10). § Patients are considered contagious until the scabs have crusted over and fallen off and a fresh layer of intact skin has formed underneath. Transmission of monkeypox can occur through direct contact with the infectious rash, scabs, or body fluids, through respiratory secretions during prolonged face-to-face contact or intimate physical contact, or through touching items, such as clothing or linens, that previously touched a patient’s infectious rash or body fluids. After an incubation period of approximately 1–2 weeks, a prodrome, characterized by fever and lymphadenopathy occurs, which is followed by the onset of a deep-seated vesicular or pustular rash that often begins centrally and spreads to the limbs ( 11). Signs and Symptoms: Classically, monkeypox occurs in three stages. Prevention and treatment considerations will be updated as more information becomes available. Although data are limited for monkeypox in patients with HIV, prompt diagnosis, treatment, and prevention might reduce the risk for adverse outcomes and limit monkeypox spread. Pre- and postexposure prophylaxis can be considered with JYNNEOS vaccine, if indicated. No identified drug interactions would preclude coadministration of tecovirimat with antiretroviral therapy (ART) for HIV infection. Treatment of monkeypox with tecovirimat as a first-line agent is available through CDC for compassionate use through an investigational drug protocol. † Available summary surveillance data from the European Union, England, and the United States indicate that among MSM patients with monkeypox for whom HIV status is known, 28%–51% have HIV infection ( 3– 10). Monkeypox was declared a public health emergency in the United States on August 4, 2022. Since May 2022, the World Health Organization (WHO) has reported a multinational outbreak of monkeypox centered in Europe and North America, with approximately 25,000 cases reported worldwide the current outbreak is disproportionately affecting gay, bisexual, and other men who have sex with men (MSM) ( 2). The last reported outbreak in the United States, in 2003, was linked to contact with infected prairie dogs that had been housed or transported with African rodents imported from Ghana ( 1). Monkeypox virus, an orthopoxvirus sharing clinical features with smallpox virus, is endemic in several countries in Central and West Africa.
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