Thread by @kakape

When I talked to @BrendaCrabtreeR a few days ago about #mpox she told me the story of a patient she helped to treat in Mexico City in June: a man in his 30s who did not know that he was also living with HIV.

science.org/content/articl…

@BrendaCrabtreeR The young man’s immune system was so weak it could not keep the monkeypox virus in check. He had painful necrotizing lesions spreading across his skin and the virus had spread to his lungs too. “He just kept getting worse and worse and worse,” @BrendaCrabtreeR told me.

@BrendaCrabtreeR No vaccine or treatments are available in Mexico. Desperate, the doctors transferred blood plasma from a colleague that had been vaccinated in the US to the patient hoping the antibodies might help fight the virus. But they could not save the patient. He died a few weeks later.

@BrendaCrabtreeR Today, a paper came out in @TheLancet in which this young man is just one of 382 patients with advanced HIV infection that also got infected with mpox, one of 27 people who died.

thelancet.com/journals/lance…

@BrendaCrabtreeR @TheLancet The report makes it clear how deadly mpox can be in patients with a low CD4 cell count: Of 179 patients with a CD4 cell count of less than 200, 27 died.
The disease is not just more severe in these patients, @oriolmitja told me. “It’s like a different disease.”

@BrendaCrabtreeR @TheLancet @oriolmitja Some consequences are clear, @oriolmitja told me: Anyone with mpox should also be tested for HIV, so that doctors can prioritise those at highest risk for any treatments (if any are available). People living with HIV should also be prioritised for vaccination, he told me.

@BrendaCrabtreeR @TheLancet @oriolmitja But the report also points out a dilemma: Some patients when started on antiretrovirals appeared to develop "immune reconstitution inflammatory syndrome": the recovering immune system responds to the existing infection - here mpox - with an overzealous inflammatory response.

@BrendaCrabtreeR @TheLancet @oriolmitja More than half the patients in which this syndrome was suspected, died.
As @Boghuma told me: “We are grappling with these scenarios and clinicians do not know what the best approach is at this time.”

@BrendaCrabtreeR @TheLancet @oriolmitja @Boghuma Two things strike me:
1. This is another example of how inequities and vulnerabilities can create more inequity and more vulnerability.

@BrendaCrabtreeR @TheLancet @oriolmitja @Boghuma After all, men who have sex with men are much more likely to acquire an HIV infection than the general public. But they are also less likely in many places to access testing and treatment. Now mpox is affecting the same population.

@BrendaCrabtreeR @TheLancet @oriolmitja @Boghuma "This creates a dangerous situation, in which our failures to address the AIDS epidemic among this population, now may create new risks for HIV+ MSM of severe mpox disease and death", @gregggonsalves told me.

@BrendaCrabtreeR @TheLancet @oriolmitja @Boghuma @gregggonsalves 2. I'm struck how easily we forget about individual suffering (even more so I worry after the experiences in the last years with #covid19).
As @BrendaCrabtreeR told me: The numbers may seem small. "But people do suffer from mpox and people do die from mpox."

@BrendaCrabtreeR @TheLancet @oriolmitja @Boghuma @gregggonsalves And so my mind is stuck on the story of this one patient in his 30s, who died in a hospital bed in Mexico City last summer, surrounded by doctors desperate for anything to treat him with and yet unable to do anything for him.

@BrendaCrabtreeR @TheLancet @oriolmitja @Boghuma @gregggonsalves My story is here:
science.org/content/articl…
The paper:
thelancet.com/journals/lance…

One of the authors @dr_michaelmarks has a thread here:

https://twitter.com/dr_michaelmarks/status/1628115784860934145

And another author, @profchloeorkin, who presented the data at #CROI today has a great thread:

https://twitter.com/profchloeorkin/status/1628115418387779606?s=20