Mpox

Question 1

What is mpox?

Answer 1

Mpox is a zoonotic viral disease caused by mpox virus, an enveloped double-stranded DNA virus belonging to the Orthopoxvirus genus of the Poxviridae family.

Question 2

Where does mpox virus circulate?

Answer 2

Mpox virus circulates among certain small mammals found in the forested regions of some parts of Africa.

Question 3

What are the two distinct clades of mpox virus?

Answer 3

Clade I (Congo Basin clade) and Clade II (West African clade).

Question 4

Which clade of mpox virus is associated with more severe disease?

Answer 4

Clade I is associated with more severe disease and more human-to-human transmission than Clade II.

Question 5

Who is at greatest risk for serious infection and death from mpox?

Answer 5

Children <8 years of age and developing fetuses infected perinatally.

Question 6

What was the first notable mpox outbreak in the United States associated with?

Answer 6

The first notable mpox outbreak occurred in the United States in 2003 and was associated with the importation of small African mammals.

Question 7

How was mpox transmitted during the 2003 outbreak in the U.S.?

Answer 7

Transmission occurred through direct contact or contaminated fomites.

Question 8

What percentage of mpox infections in 2022 were transmitted sexually?

Answer 8

The majority of infections in 2022 were transmitted sexually through intimate contact.

Question 9

Which groups have been disproportionately affected by mpox infections?

Answer 9

Gay, bisexual, same-gender-loving men, and other men who have sex with men (MSM).

Question 10

What is the overall mortality rate for Clade II mpox infection?

Answer 10

The overall mortality rate is low (<1%).

Question 11

What are the prodromal symptoms of mpox?

Answer 11

Fever, headache, lymphadenopathy, myalgias, or fatigue.

Question 12

What characterizes the rash associated with mpox?

Answer 12

A distinctive rash progresses from macules to papules, vesicles, pustules, and ultimately crusted lesions.

Question 13

How can mpox lesions be characterized during the 2022 outbreak?

Answer 13

Rash commonly occurs as anogenital or oropharyngeal/perioral lesions.

Question 14

What can severe gastrointestinal manifestations of mpox lead to?

Answer 14

Hospitalization for enhanced symptom control, including pain management.

Question 15

What is the primary method for confirming a diagnosis of mpox?

Answer 15

Detection of mpox virus DNA in a clinical specimen using polymerase chain reaction (PCR).

Question 16

What specimen is recommended for mpox diagnosis?

Answer 16

Skin lesion material, including swabs of a lesion’s surface, lesion exudate, or lesion crusts.

Question 17

What is the preferred vaccine for mpox before exposure?

Answer 17

MVA-BN vaccine, sold as JYNNEOS in the United States.

Question 18

How is the JYNNEOS vaccine administered?

Answer 18

In two doses (0.1 mL ID or 0.5 mL SQ) 28 days apart.

Question 19

What is contraindicated for pregnant or immunocompromised individuals regarding vaccination?

Answer 19

Administration of live, replicating vaccinia vaccines (e.g., ACAM2000).

Question 20

What is recommended for unvaccinated individuals with HIV after exposure to mpox?

Answer 20

Post-exposure vaccination as soon as possible, ideally within 4 days after exposure.

Question 21

What are the two doses of JYNNEOS given for post-exposure vaccination?

Answer 21

0.1 mL ID or 0.5 mL SQ, administered 28 days apart.

Question 22

What should individuals with advanced immunosuppression consider regarding mpox post-exposure prophylaxis?

Answer 22

Tecovirimat or VIGIV on a case-by-case basis.

Question 23

What is the effectiveness range of JYNNEOS against symptomatic mpox infection after two doses?

Answer 23

66-89%.

Question 24

What is the key recommendation for preventing mpox exposure?

Answer 24

Avoid close intimate contact with individuals showing symptoms or rash suspicious for mpox.

Question 25

True or False: Severe cases of mpox have been reported in pediatric patients and pregnant people.

Answer 25

False.

Question 26

Fill in the blank: The preferred vaccine for mpox is _______.

Answer 26

JYNNEOS.

Question 27

What is the effectiveness range of JYNNEOS against symptomatic mpox infection after one dose?

Answer 27

36-75% ## Footnote Effectiveness increases to 66-89% after two doses.

Question 28

For individuals with advanced immunosuppression or contraindications to vaccination, what can be used for mpox post-exposure prophylaxis?

Answer 28

Tecovirimat or vaccinia immune globulin intravenous (VIGIV) ## Footnote Use should be on a case-by-case basis in consultation with an expert.

Question 29

What is the recommended dosage of tecovirimat for patients weighing less than 120 kg?

Answer 29

600 mg PO every 12 hours or 200 mg IV every 12 hours ## Footnote For patients ≥120 kg, the dosing frequency changes.

Question 30

What is the recommended adjunctive therapy for severe mpox disease?

Answer 30

Cidofovir or brincidofovir ## Footnote Cidofovir is contraindicated in specific renal conditions.

Question 31

What should be done before and after administering cidofovir?

Answer 31

Saline hydration and probenecid ## Footnote Probenecid helps mitigate nephrotoxicity.

Question 32

What is the recommended use of trifluridine in treating ocular mpox?

Answer 32

1 drop into affected eye(s) every 2 hours when awake ## Footnote Max: 9 drops/day until reepithelialization.

Question 33

In what scenario should vaccination with live virus vaccines be delayed?

Answer 33

Until 3 months after VIGIV administration ## Footnote Revaccination is needed for those who received VIGIV shortly after vaccination.

Question 34

What are the common adverse effects of tecovirimat?

Answer 34

Headache and nausea ## Footnote Monitoring for renal function is also recommended.

Question 35

What is the teratogenic risk associated with cidofovir and brincidofovir in pregnancy?

Answer 35

Both are not recommended for use in pregnancy ## Footnote They have been shown to be teratogenic in animal studies.

Question 36

What is the importance of initiating antiretroviral therapy (ART) in patients with HIV and mpox?

Answer 36

To improve T and B cell function ## Footnote This helps modulate mpox disease severity and prevent mortality.

Question 37

What is the potential complication of initiating ART in patients with advanced HIV?

Answer 37

Immune reconstitution inflammatory syndrome (IRIS) ## Footnote IRIS could worsen mpox disease.

Question 38

What is the significance of monitoring renal function in patients receiving IV cidofovir?

Answer 38

To prevent severe renal injury ## Footnote Nephrotoxicity can occur, necessitating close monitoring.

Question 39

What is a potential adverse effect of brincidofovir?

Answer 39

Diarrhea and elevations in hepatic enzymes ## Footnote Monitoring liver function parameters is crucial.

Question 40

What is the recommended first-line antiviral for pregnant individuals with mpox?

Answer 40

Tecovirimat ## Footnote It is considered safe for use during pregnancy.

Question 41

What should clinicians consider before administering cidofovir?

Answer 41

Renal function and proteinuria levels ## Footnote Administration is contraindicated in certain renal conditions.

Question 42

What is the maximum duration of trifluridine use to avoid corneal toxicity?

Answer 42

21 days ## Footnote Prolonged use beyond this may cause corneal epithelial toxicity.

Question 43

True or False: Cidofovir is FDA-approved for treating cytomegalovirus (CMV) retinitis.

Answer 43

True ## Footnote It is used in patients with advanced HIV.

Question 44

What additional therapy may benefit patients with severe immunocompromise and mpox?

Answer 44

Extended treatment with antivirals ## Footnote This is considered if new lesions occur or worsening is observed.

Question 45

What should patients receiving IV cidofovir be monitored for?

Answer 45

Nephrotoxicity and uveitis ## Footnote Regular blood tests are necessary before each infusion.

Question 46

What is the role of the CDC in the management of mpox treatment?

Answer 46

Provides clinical consultation and guidance ## Footnote Clinicians can contact the CDC for patient management questions.

Question 47

What should be considered if serum aminotransferases are elevated and persist above 10 times the upper limit of normal before the second dose of brincidofovir?

Answer 47

Consider not giving the second dose of brincidofovir. ## Footnote This is important to prevent potential liver damage.

Question 48

What clinical signs and symptoms indicate that the second dose of brincidofovir should not be given?

Answer 48

Elevation of serum aminotransferases accompanied by clinical signs and symptoms of liver inflammation or increasing direct bilirubin, alkaline phosphatase, or international normalized ratio. ## Footnote These indicators suggest liver distress.

Question 49

What should male patients be counseled about regarding brincidofovir?

Answer 49

The risk for irreversible effects on male fertility based on testicular toxicity observed in animal studies. ## Footnote This is classified as a strong recommendation (AII).

Question 50

What contraceptive measures should individuals of childbearing potential take during treatment with brincidofovir?

Answer 50

Use effective contraception and/or condoms during treatment and for at least 4 months after the last dose. ## Footnote This is to prevent potential teratogenic effects.

Question 51

What factors increase the likelihood of clinical failure of therapy for mpox?

Answer 51

Lack of substantial immune reconstitution after ART initiation or optimization and severe immunocompromised status. ## Footnote Treatment adherence and drug levels also play a role.

Question 52

What should be done if clinical manifestations of mpox do not improve after a 14-day course of tecovirimat?

Answer 52

Initiate IV tecovirimat and assess the addition of other therapeutics, including brincidofovir or cidofovir and VIGIV. ## Footnote This is recommended if gastrointestinal absorption is a concern.

Question 53

What is the barrier to viral resistance for tecovirimat?

Answer 53

Tecovirimat has a relatively low barrier to viral resistance. ## Footnote Single amino acid substitutions in the F13L gene can significantly reduce its antiviral activity.

Question 54

What should clinicians suspect if new lesions form after at least 7 days of tecovirimat treatment?

Answer 54

Resistance to tecovirimat. ## Footnote In such cases, consider additional therapeutics like cidofovir or brincidofovir.

Question 55

What is recommended for patients with positive PCR test results until lesions resolve?

Answer 55

Continue antiviral medications if viable mpox virus is detected by culture. ## Footnote This indicates ongoing infection and replication.

Question 56

What are potential adverse outcomes of mpox infection during pregnancy?

Answer 56

* Spontaneous pregnancy loss * Stillbirth * Preterm delivery * Neonatal mpox infection ## Footnote These outcomes highlight the risks associated with mpox during pregnancy.

Question 57

What vaccine should be used for people who are pregnant, breastfeeding, or trying to become pregnant?

Answer 57

JYNNEOS should be used because it is non-replication competent. ## Footnote This vaccine has shown no evidence of harm to the developing fetus in animal studies.

Question 58

What is contraindicated for pregnant or breastfeeding individuals regarding vaccination?

Answer 58

ACAM2000, due to its replication-competent virus risks. ## Footnote It poses risks of pregnancy loss and congenital defects.

Question 59

What is the first-line antiviral treatment for people who are pregnant, recently pregnant, or breastfeeding?

Answer 59

Tecovirimat. ## Footnote Limited information on its impact on reproductive development exists, but no specific fetal effects were observed in animal studies.

Question 60

What should be avoided during pregnancy due to teratogenic effects?

Answer 60

Cidofovir and brincidofovir. ## Footnote These agents are not recommended for use in pregnancy.