Mpox Flashcards
What is mpox?
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.
Where does mpox virus circulate?
Mpox virus circulates among certain small mammals found in the forested regions of some parts of Africa.
What are the two distinct clades of mpox virus?
Clade I (Congo Basin clade) and Clade II (West African clade).
Which clade of mpox virus is associated with more severe disease?
Clade I is associated with more severe disease and more human-to-human transmission than Clade II.
Who is at greatest risk for serious infection and death from mpox?
Children <8 years of age and developing fetuses infected perinatally.
What was the first notable mpox outbreak in the United States associated with?
The first notable mpox outbreak occurred in the United States in 2003 and was associated with the importation of small African mammals.
How was mpox transmitted during the 2003 outbreak in the U.S.?
Transmission occurred through direct contact or contaminated fomites.
What percentage of mpox infections in 2022 were transmitted sexually?
The majority of infections in 2022 were transmitted sexually through intimate contact.
Which groups have been disproportionately affected by mpox infections?
Gay, bisexual, same-gender-loving men, and other men who have sex with men (MSM).
What is the overall mortality rate for Clade II mpox infection?
The overall mortality rate is low (<1%).
What are the prodromal symptoms of mpox?
Fever, headache, lymphadenopathy, myalgias, or fatigue.
What characterizes the rash associated with mpox?
A distinctive rash progresses from macules to papules, vesicles, pustules, and ultimately crusted lesions.
How can mpox lesions be characterized during the 2022 outbreak?
Rash commonly occurs as anogenital or oropharyngeal/perioral lesions.
What can severe gastrointestinal manifestations of mpox lead to?
Hospitalization for enhanced symptom control, including pain management.
What is the primary method for confirming a diagnosis of mpox?
Detection of mpox virus DNA in a clinical specimen using polymerase chain reaction (PCR).
What specimen is recommended for mpox diagnosis?
Skin lesion material, including swabs of a lesion’s surface, lesion exudate, or lesion crusts.
What is the preferred vaccine for mpox before exposure?
MVA-BN vaccine, sold as JYNNEOS in the United States.
How is the JYNNEOS vaccine administered?
In two doses (0.1 mL ID or 0.5 mL SQ) 28 days apart.
What is contraindicated for pregnant or immunocompromised individuals regarding vaccination?
Administration of live, replicating vaccinia vaccines (e.g., ACAM2000).
What is recommended for unvaccinated individuals with HIV after exposure to mpox?
Post-exposure vaccination as soon as possible, ideally within 4 days after exposure.
What are the two doses of JYNNEOS given for post-exposure vaccination?
0.1 mL ID or 0.5 mL SQ, administered 28 days apart.
What should individuals with advanced immunosuppression consider regarding mpox post-exposure prophylaxis?
Tecovirimat or VIGIV on a case-by-case basis.
What is the effectiveness range of JYNNEOS against symptomatic mpox infection after two doses?
66-89%.
What is the key recommendation for preventing mpox exposure?
Avoid close intimate contact with individuals showing symptoms or rash suspicious for mpox.
True or False: Severe cases of mpox have been reported in pediatric patients and pregnant people.
False.
Fill in the blank: The preferred vaccine for mpox is _______.
JYNNEOS.
What is the effectiveness range of JYNNEOS against symptomatic mpox infection after one dose?
36-75%
Effectiveness increases to 66-89% after two doses.
For individuals with advanced immunosuppression or contraindications to vaccination, what can be used for mpox post-exposure prophylaxis?
Tecovirimat or vaccinia immune globulin intravenous (VIGIV)
Use should be on a case-by-case basis in consultation with an expert.
What is the recommended dosage of tecovirimat for patients weighing less than 120 kg?
600 mg PO every 12 hours or 200 mg IV every 12 hours
For patients ≥120 kg, the dosing frequency changes.
What is the recommended adjunctive therapy for severe mpox disease?
Cidofovir or brincidofovir
Cidofovir is contraindicated in specific renal conditions.
What should be done before and after administering cidofovir?
Saline hydration and probenecid
Probenecid helps mitigate nephrotoxicity.
What is the recommended use of trifluridine in treating ocular mpox?
1 drop into affected eye(s) every 2 hours when awake
Max: 9 drops/day until reepithelialization.
In what scenario should vaccination with live virus vaccines be delayed?
Until 3 months after VIGIV administration
Revaccination is needed for those who received VIGIV shortly after vaccination.
What are the common adverse effects of tecovirimat?
Headache and nausea
Monitoring for renal function is also recommended.
What is the teratogenic risk associated with cidofovir and brincidofovir in pregnancy?
Both are not recommended for use in pregnancy
They have been shown to be teratogenic in animal studies.
What is the importance of initiating antiretroviral therapy (ART) in patients with HIV and mpox?
To improve T and B cell function
This helps modulate mpox disease severity and prevent mortality.
What is the potential complication of initiating ART in patients with advanced HIV?
Immune reconstitution inflammatory syndrome (IRIS)
IRIS could worsen mpox disease.
What is the significance of monitoring renal function in patients receiving IV cidofovir?
To prevent severe renal injury
Nephrotoxicity can occur, necessitating close monitoring.
What is a potential adverse effect of brincidofovir?
Diarrhea and elevations in hepatic enzymes
Monitoring liver function parameters is crucial.
What is the recommended first-line antiviral for pregnant individuals with mpox?
Tecovirimat
It is considered safe for use during pregnancy.
What should clinicians consider before administering cidofovir?
Renal function and proteinuria levels
Administration is contraindicated in certain renal conditions.
What is the maximum duration of trifluridine use to avoid corneal toxicity?
21 days
Prolonged use beyond this may cause corneal epithelial toxicity.
True or False: Cidofovir is FDA-approved for treating cytomegalovirus (CMV) retinitis.
True
It is used in patients with advanced HIV.
What additional therapy may benefit patients with severe immunocompromise and mpox?
Extended treatment with antivirals
This is considered if new lesions occur or worsening is observed.
What should patients receiving IV cidofovir be monitored for?
Nephrotoxicity and uveitis
Regular blood tests are necessary before each infusion.
What is the role of the CDC in the management of mpox treatment?
Provides clinical consultation and guidance
Clinicians can contact the CDC for patient management questions.
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?
Consider not giving the second dose of brincidofovir.
This is important to prevent potential liver damage.
What clinical signs and symptoms indicate that the second dose of brincidofovir should not be given?
Elevation of serum aminotransferases accompanied by clinical signs and symptoms of liver inflammation or increasing direct bilirubin, alkaline phosphatase, or international normalized ratio.
These indicators suggest liver distress.
What should male patients be counseled about regarding brincidofovir?
The risk for irreversible effects on male fertility based on testicular toxicity observed in animal studies.
This is classified as a strong recommendation (AII).
What contraceptive measures should individuals of childbearing potential take during treatment with brincidofovir?
Use effective contraception and/or condoms during treatment and for at least 4 months after the last dose.
This is to prevent potential teratogenic effects.
What factors increase the likelihood of clinical failure of therapy for mpox?
Lack of substantial immune reconstitution after ART initiation or optimization and severe immunocompromised status.
Treatment adherence and drug levels also play a role.
What should be done if clinical manifestations of mpox do not improve after a 14-day course of tecovirimat?
Initiate IV tecovirimat and assess the addition of other therapeutics, including brincidofovir or cidofovir and VIGIV.
This is recommended if gastrointestinal absorption is a concern.
What is the barrier to viral resistance for tecovirimat?
Tecovirimat has a relatively low barrier to viral resistance.
Single amino acid substitutions in the F13L gene can significantly reduce its antiviral activity.
What should clinicians suspect if new lesions form after at least 7 days of tecovirimat treatment?
Resistance to tecovirimat.
In such cases, consider additional therapeutics like cidofovir or brincidofovir.
What is recommended for patients with positive PCR test results until lesions resolve?
Continue antiviral medications if viable mpox virus is detected by culture.
This indicates ongoing infection and replication.
What are potential adverse outcomes of mpox infection during pregnancy?
- Spontaneous pregnancy loss
- Stillbirth
- Preterm delivery
- Neonatal mpox infection
These outcomes highlight the risks associated with mpox during pregnancy.
What vaccine should be used for people who are pregnant, breastfeeding, or trying to become pregnant?
JYNNEOS should be used because it is non-replication competent.
This vaccine has shown no evidence of harm to the developing fetus in animal studies.
What is contraindicated for pregnant or breastfeeding individuals regarding vaccination?
ACAM2000, due to its replication-competent virus risks.
It poses risks of pregnancy loss and congenital defects.
What is the first-line antiviral treatment for people who are pregnant, recently pregnant, or breastfeeding?
Tecovirimat.
Limited information on its impact on reproductive development exists, but no specific fetal effects were observed in animal studies.
What should be avoided during pregnancy due to teratogenic effects?
Cidofovir and brincidofovir.
These agents are not recommended for use in pregnancy.
