Treatment Considerations for Severe Manifestations of Monkeypox

Core Concepts

Effective treatment strategies for severe monkeypox manifestations are crucial for patient outcomes.

Abstract

Standalone Note here

Ocular Infections

Clinical Manifestations:

Symptoms include eye pain, redness, drainage, foreign body sensation, vision changes, or periorbital swelling.
Lesions can manifest as blepharitis, conjunctivitis, or keratitis.

Diagnostic Findings:

Testing swabs for OPXV by PCR confirms ocular infection.

Treatment:

Prompt initiation of tecovirimat and trifluridine.
Prophylactic use of trifluridine in high-risk patients.

Other Considerations:

Adverse events from trifluridine, avoid further eye irritation.

Neurologic Complications

Clinical Manifestations:

Encephalitis, myelitis with severe headache, altered mental status.

Diagnostic Findings:

CSF analysis, MRI for brain or spinal cord lesions.

Treatment:

MCMs, immunomodulatory therapy for neurologic disease.

Other Considerations:

Investigate other neurologic diseases with similar presentations.

Myopericarditis

Clinical Manifestations:

Chest pain, shortness of breath, palpitations.

Diagnostic Findings:

Elevated cardiac biomarkers, ECG changes, myocardial pathology.

Treatment:

Standard care, MCMs to limit viral spread.

Other Considerations:

Investigate other causes of myopericarditis.

Mucosal Lesions Complications

Clinical Manifestations:

Impaired activities from painful or obstructing lesions.

Diagnostic Findings:

Diagnosis by physical examination and sampling lesions.

Treatment:

Prompt initiation of systemic MCMs, avoid routine antimicrobial agents.

Other Considerations:

Consult specialists early, manage pain, diagnose coinfections.

Immunocompromised Patients

Clinical Manifestations:

Large skin lesions, organ dysfunction, systemic illness.

Diagnostic Findings:

New or worsening skin lesions, organ involvement.

Treatment:

Optimize immune function, use MCMs, wound care critical.

Other Considerations:

Consult experts, consider extended MCMs duration if needed.

Stats

Involvement of the ocular surface can manifest as blepharitis, conjunctivitis, or keratitis; discrete lesions might be present.
Uncontrolled viral spread can manifest as the appearance of new skin lesions or worsening of existing lesions.
Diffuse skin lesions might cause insensible fluid losses requiring intensive fluid management.

Quotes

"Prompt initiation of tecovirimat and trifluridine should be considered."
"Immune function should be optimized through interventions such as effective HIV antiretrovirals."

Key Insights Distilled From

Treatment Considerations for Severe Manifestations of Mpox

by Agam K. Rao at www.medscape.com 05-17-2023

http://www.medscape.com/viewarticle/989191

Deeper Inquiries

How can the treatment strategies for monkeypox be adapted for different patient populations?

In adapting treatment strategies for monkeypox in different patient populations, several factors need to be considered. For immunocompromised patients, optimizing immune function through interventions like effective HIV antiretrovirals and reduced immunomodulatory therapy is crucial. Prompt initiation of tecovirimat, possibly in the intravenous formulation, along with cidofovir or brincidofovir, and VIGIV should be considered. Wound care is essential to ensure healing and prevent complications. For patients with ocular infections, prompt initiation of tecovirimat and topical administration of trifluridine is recommended. Trifluridine can also be used prophylactically in high-risk patients. Treatment should be tailored based on the severity of the disease, immune status, and potential complications in each patient population.

What are the potential risks associated with prolonged use of trifluridine in ocular infections?

Prolonged use of trifluridine in ocular infections can pose certain risks. Adverse events may occur from prolonged use, including ocular irritation, burning, stinging, or blurred vision. There is a potential for corneal toxicity with extended use, leading to epithelial keratopathy or punctate keratitis. Additionally, trifluridine resistance can develop with prolonged treatment, reducing its effectiveness over time. It is essential to monitor patients closely for any signs of adverse reactions or worsening of ocular symptoms during treatment with trifluridine and consider alternative therapies if necessary.

How can the immune dysregulation in severe monkeypox illness be better understood and managed?

To better understand and manage immune dysregulation in severe monkeypox illness, several approaches can be taken. Clinicians should weigh the risks and benefits of immunomodulatory or immunosuppressive therapy in cases of neurologic complications. Optimal immune function aids recovery from monkeypox, so interventions to optimize immune function, such as reducing immunomodulatory therapy in immunocompromised patients, should be considered. The role of immune dysregulation in severe illness is not fully known, so further research is needed to elucidate the mechanisms involved. Close clinical monitoring for complications like secondary bacterial infections and sepsis is crucial in managing severe monkeypox cases where immune dysregulation may play a role.