I.Azina [1], A.Soha[1], B.Rozentale[1], S.Nikisins[2], Jelena Eglite[3].

Affiliates

1 Latvian Centre of Infectious Diseases, Riga East Clinical University Hospital, Latvia. 2 Laboratory Service of Latvian Centre of Infectious Diseases, Riga East Clinical University Hospital, Latvia. 3 MVI Joint Laboratory of Clinical Immunology and Immunogenetics, Riga Stradinš University, 7 Ratsupites Str., LV-1067, Riga, Latvia

Abstract

Human monkeypox (MPX) is a zoonotic viral disease caused by a member of the Orthopoxvirus genus, the monkeypox virus (MPXV). The majority of cases of MPXV were between male (98.8%), and mainly reported in MSM (49.6%), the rest of the cases were in heterosexual men (1.1%), unknown (13,6%) or missing (35.4%) sexual orientation status. The proportion of PLHIV among patients with MPXV was 37%, per ECDC-WHO.
Latvia has reported a total of 4 confirmed cases of MPXV at the Latvian Infectious Disease center by August 2022, all cases being MSM and imported, among them – one HIV positive patient (our case).
According to previous studies in Africa people with uncontrolled HIV had worse outcomes of MPXV, including more extensive and longer-lasting lesions, more complications, and several deaths.
At the same time, SARS-CoV-2 is still a major cause of morbidity and mortality globally. Based on the current published data immunocompromised patients with uncontrolled HIV infection are at risk of poor outcomes of COVID-19.

Case Report
In this study we present the clinical outcome of one documented case of co-infection with MPXV and SARS-CoV-2 in well-managed HIV-positive patient.
Our patient is a 35-year-old MSM Caucasian male diagnosed with HIV I A III stage 13 years ago with a history of Kaposi’s sarcoma in 2013 ( HIV I C III) and currently in remission, no other underlying chronic diseases. He has been receiving ART therapy regularly for the last 9 years with well-controlled immune status, fully vaccinated with 3 doses of COVID-19 vaccine. He spent 10 days in Germany having multiple unprotected intercourses with men. At the end of this trip, he developed fever up to 38 C without any other symptoms. Five days later, a rash in the form of small vesicles with erythematous halo started to develop on his palms, feet, legs and around the anus. A patient was admitted to the department of dangerous and droplet infections of Latvian Centre of Infectious Diseases with suspected MPXV.
At our department MPXV and SARS CoV-2 were confirmed in June 2022 by a positive RT-PCR tests through nasopharyngeal swab and from the lesion surfaces. The course of Covid-19 infection was asymptomatic, immune status was well-controlled (CD4+ cell count of 602 cells/mm3, HIV RNS – not detected). The patient fully recovered without specific treatment and was discharged on day 6, continuing isolation at home for 3 weeks. Four weeks later recovery blood examination showed CD4+ cell count of 409 cells/mm3, HIV RNS – not detected).

Conclusion
Based on the current published data and our findings, it can be assumed that the course of Covid-19 in the vaccinated well-controlled HIV patients does not differ from the typical clinical manifestations and outcome of COVID-19 in general population.
Considering the parallel spread of Covid-19 pandemic and MRXV outbreak, special attention should be paid to minimizing the possible severe complications using targeted MPXV vaccination among immunocompromised HIV+ MSM patients, as appropriate vaccination is an essential measure to protect these patients against poor outcomes of overlapping COVID-19 and MPXV infection (hospitalization, risk of long-term health problems, severe disease, death). In Latvia, MPXV vaccine “Imvanex” is available since 15th of August, 2022, and specific recommendations have been developed for priority groups of patients.