英国伦敦玛丽女王大学Chloe M Orkin团队对艾滋病毒晚期感染者的猴痘感染情况进行了全球病例分析。该研究于2023年2月21日发表在《柳叶刀》杂志上。

在2022年多国猴痘疫情中，艾滋病毒感染者占猴痘感染人数的38-50%。大多数报告的病例发生在CD4细胞计数高的人群中，结果与未感染艾滋病毒的人群相似。新出现的数据表明，晚期艾滋病毒感染者的临床预后更差，死亡率更高。研究组描述了一组艾滋病毒感染者和低CD4细胞计数（CD4 <350细胞/mm³）中猴痘的临床特征和结局。

来自19个国家的临床医生网络提供了2022年5月11日至2023年1月18日期间艾滋病毒感染者中确诊的猴痘病例数据。捐助中心完成了不确定的结构化病例报告表，以包括与艾滋病毒感染者相关的利益变量，并反映更严重的结果。研究组将这一系列病例限制为年龄大于18岁的HIV感染者，CD4细胞计数低于350个/mm³，或者在CD4细胞计数不总是常规可用的情况下，临床分类为美国疾病控制和预防中心C期的HIV感染。研究组描述了他们的临床表现、并发症和死亡原因。分析是描述性的。

研究组纳入了382例病例的数据：367名顺性男性，4名顺性女性，10名跨性别女性。受试者年龄中位数为35岁。在猴痘诊断时，已知349人（91%）携带艾滋病毒；228名（65%）坚持抗逆转录病毒治疗（ART）；382例中有32例（8%）并发机会性疾病。中位CD4细胞计数为211个/ mm³，其中85人（22%）CD4细胞计数低于100个/mm³，94人（25%）CD4细胞计数为100-200个/mm³。总的来说，382人中有193人（51%）病毒载量无法检测。CD4细胞计数低于100个/mm³的患者比CD4细胞计数超过300个/mm³的患者更常见严重并发症，包括坏死性皮肤病变（54% vs 7%），肺部受累偶尔伴有结节（29% vs 0%），继发性感染和败血症（44% vs 9%）。

总体而言，382人中有107人（28%）住院，其中27人（25%）死亡。所有死亡都发生在CD4细胞计数低于200个/mm³的人群中。在CD4细胞计数低于200个/mm³的人群中，艾滋病毒载量高的人死亡更多。85例开始或重新开始抗逆转录病毒治疗的患者中有21例（25%）怀疑有猴痘免疫重建炎症综合征，其中21例中有12例（57%）死亡。382例患者中有62例（16%）接受了特考韦瑞治疗，7例（2%）接受了西多福韦或布林西多福韦治疗。3人经实验室确认对特考韦瑞耐药。

研究结果表明，在晚期免疫抑制的情况下，严重坏死性猴痘表现为AIDS定义的病症，暴发性皮肤病和全身症状以及死亡的发病率很高。

附：英文原文

Title: Mpox in people with advanced HIV infection: a global case series

Author: Oriol Mitjà, Andrea Alemany, Michael Marks, Jezer I Lezama Mora, Juan Carlos Rodríguez-Aldama, Mayara Secco Torres Silva, Ever Arturo Corral Herrera, Brenda Crabtree-Ramirez, José Luis Blanco, Nicolo Girometti, Valentina Mazzotta, Aniruddha Hazra, Macarena Silva, Juan José Montenegro-Idrogo, Kelly Gebo, Jade Ghosn, María Fernanda Pea Vázquez, Eduardo Matos Prado, Uche Unigwe, Judit Villar-García, Noah Wald-Dickler, Jason Zucker, Roger Paredes, Alexandra Calmy, Laura Waters, Cristina Galvan-Casas, Sharon Walmsley, Chloe M Orkin, Viviana Leiro, Lucila Marchetta, Patricia Fernandez Pardal, María Inés Figueroa, Pedro Cahn, Katharina Grabmeier-Pfistershammer, Agnes Libois, Laurens Liesenborghs, Beatriz Grinsztejn, Mauro Schechter, Alberto dos Santos de Lemos, Alvaro Furtado Costa, Simone Queiroz Rocha, José Valdez Madruga, Darrell H. S. Tan, Sharmistha Mishra, Shreya Shah, Camila Jorquera, Alberto Castillo, Mauricio Carrión, Nelson Cevallos, Romain Palich, Valerie Pourcher, Emma Rubenstein, Pascal Migaud, Christoph Boesecke, Christian Hoffmann, Konstantinos Protopapas, Silvia Nozza, Anna Maria Cattelan, Cristina Mussini, Antonella dArminio Monforte, Raúl Adrian Cruz Flores, Edgar Pérez Barragán, Alma Leticia Rodríguez Guzmán, Dimie Ogoina, Nneka Marian Chika-Igwenyi, Onyeaghala Chizaram, Jenny Valverde López, Angelica García Tello, Maria Ubals, Martí Vall, Adrià Mendoza, Clara Suer, Bonaventura Clotet, Jordi Bechini, Jose A Lepe, M. Dolores Navarro-Amuedo, Jose Ignacio Bernadino, Alba Català, Eloy José Tarín Vicente, Borja González Rodríguez, Sergi Rodriguez-Mercader, Francisca Sánchez-Martinez, Esperanza Caas-Ruano, Laura Parra-Navarro, Finn Filén, Carmen Tallón de Lara, Dominique Braun, Vanja Piezzi, Michael Burkhard, Helen Kovari, Anja Mnch, Jake Dunning, Pedro Simoes, Achyuta Nori, Sarah Keegan, John P Thornhill, Vanessa Apea, Teymur Noori, Joyce L. Jones, Seth Judson, Elizabeth A. Gilliams, Matthew Hammill, Jeanne Keruly, Andrés F. Henao Martínez, Aung Lin, Jessica So, Kusha Davar, Diana Villareal

Issue&Volume: 2023-02-21

Abstract:

Background

People living with HIV have accounted for 38–50% of those affected in the 2022 multicountry mpox outbreak. Most reported cases were in people who had high CD4 cell counts and similar outcomes to those without HIV. Emerging data suggest worse clinical outcomes and higher mortality in people with more advanced HIV. We describe the clinical characteristics and outcomes of mpox in a cohort of people with HIV and low CD4 cell counts (CD4 <350 cells per mm3).

Methods

A network of clinicians from 19 countries provided data of confirmed mpox cases between May 11, 2022, and Jan 18, 2023, in people with HIV infection. Contributing centres completed deidentified structured case report sheets to include variables of interest relevant to people living with HIV and to capture more severe outcomes. We restricted this series to include only adults older than 18 years living with HIV and with a CD4 cell count of less than 350 cells per mm3 or, in settings where a CD4 count was not always routinely available, an HIV infection clinically classified as US Centers for Disease Control and Prevention stage C. We describe their clinical presentation, complications, and causes of death. Analyses were descriptive.

Findings

We included data of 382 cases: 367 cisgender men, four cisgender women, and ten transgender women. The median age of individuals included was 35 (IQR 30–43) years. At mpox diagnosis, 349 (91%) individuals were known to be living with HIV; 228 (65%) of 349 adherent to antiretroviral therapy (ART); 32 (8%) of 382 had a concurrent opportunistic illness. The median CD4 cell count was 211 (IQR 117–291) cells per mm3, with 85 (22%) individuals with CD4 cell counts of less than 100 cells per mm3 and 94 (25%) with 100–200 cells per mm3. Overall, 193 (51%) of 382 had undetectable viral load. Severe complications were more common in people with a CD4 cell count of less than 100 cells per mm3 than in those with more than 300 cells per mm3, including necrotising skin lesions (54% vs 7%), lung involvement (29% vs 0%) occasionally with nodules, and secondary infections and sepsis (44% vs 9%). Overall, 107 (28%) of 382 were hospitalised, of whom 27 (25%) died. All deaths occurred in people with CD4 counts of less than 200 cells per mm3. Among people with CD4 counts of less than 200 cells per mm3, more deaths occurred in those with high HIV viral load. An immune reconstitution inflammatory syndrome to mpox was suspected in 21 (25%) of 85 people initiated or re-initiated on ART, of whom 12 (57%) of 21 died. 62 (16%) of 382 received tecovirimat and seven (2%) received cidofovir or brincidofovir. Three individuals had laboratory confirmation of tecovirimat resistance.

Interpretation

A severe necrotising form of mpox in the context of advanced immunosuppression appears to behave like an AIDS-defining condition, with a high prevalence of fulminant dermatological and systemic manifestations and death.

DOI: 10.1016/S0140-6736(23)00273-8

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00273-8/fulltext