Table 1.
Characteristics at the Time of Plasma Sample Collection From Patients in Whom Microbial Cell-Free DNA Sequencing Detected Monkeypox virus, July 2022–April 2023
| CP No. | Age, y; Sex | HIV Status (CD4 Count. cells/μl) | Mode of Mpox Spread | Description of Lesions if Present at Time of mcfDNA Sequencing | mcfDNA Sequencing Detections (MPM)a | Mpox Suspected or Diagnosed | Orthopoxvirus PCR Result | Mpox Severity Score, 1–23 [25, 26] | Additional Commentsb |
|---|---|---|---|---|---|---|---|---|---|
| 1c | 30–39; male | HIV/AIDS (<35) | Sexual (MSM) | Perirectal and perioral lesions, progressed to disseminated (pustular and necrotic) | HSV-2 (538) CMV (12 900) HHV-8 (316) MPXV (746 852d) PJP (1838) |
Yes | Positive | 20 | Received 3 courses of TPOXX with 2nd course PO at 1st sampling and 3rd course IV at 2nd sampling. Required hospitalization in ICU. Diagnoses included mpox, PJP, CMV colitis, HSV-2, Kaposi sarcoma. Was discharged to hospice care. |
| HHV-8 (176) MPXV (1 752 437d) PJP (1007) Proteus mirabilis (3313) Pseudomonas aeruginosa (44 638) |
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| 2 | 20–29; male | Negative | Unknown | No reported lesions | MPXV (192) | Not suspected | Not done | 2 | Presented with fever, difficulty breathing, chest pain, requiring brief hospitalization. No TPOXX. Diagnosed with acute myocarditis. |
| 3 | 30–39; male | HIV/AIDS (<1) | Unknown | Extensive distribution of lesions, especially on face and inner right thigh | CMV HSV-2 HHV-8 MPXV Primate tetraparvovirus Fusobacterium necrophorum Lactobacillus jensenii Prevotella bivia Staphylococcus aureus Streptococcus anginosus |
Yes | Positive | 23 | Received IV TPOXX. Hospitalized in ICU. Diagnosed with mpox, right thigh myositis, pneumonia, disseminated CMV. Subsequently suffered overwhelming septic shock and died. |
| 4 | 30–39; male | HIV/AIDS (278) | Unknown | Disseminated lesions including face, hands, feet, and perianal region | MPXV (205 051) | Yes | Positive | 16 | Received IV TPOXX. History of recent treatment for syphilis. Required hospitalization. Diagnosed with mpox. |
| 5 | 30–39; male | HIV (545) | Sexual (MSM) | Few dry, healing skin lesions on fingers bilaterally | MPXV (336) Streptococcus pneumoniae (606) |
Not suspected for current presentation | Not done | 0 | History of recent treatment for syphilis. Presented with acute left-sided neck mass and history of acute signs/symptoms consistent with mpox but unconfirmed and resolved ∼2 wk previously; also history of exposure to reportedly mpox-infected contact. No TPOXX. Required hospitalization. Diagnosed with left neck mass/lymphadenitis (S pneumoniae, also yielded from needle aspiration). |
| 6 | 30–39; male | HIV/AIDS (80) | Unknown | Disseminated lesions over entire body including face | HHV-8 (1376) HSV-1 (140) MPXV (145 681) |
Yes | Positive | 17 | History of Kaposi sarcoma, anal warts (suspected anal condyloma). Received PO TPOXX. Required hospitalization. Diagnosed with mpox. |
| 7c | 20–29; male | HIV/AIDS (2.14) | Suspected sexual (MSM) | Initial perirectal lesions and general skin rash progressed to diffusely spread lesions | Adenovirus B (611) HHV-8 (56) MPXV (288 440) Primate tetraparvovirus 1 (315) |
Yes | Positive | 19 | Received TPOXX × 2 (PO, then IV). Required hospitalization. Diagnosed with mpox. |
| EBV (333) Primate tetraparvovirus 1 (444) MPXV (519 762d) |
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| 8 | 20–29; male | HIV (190) | Sexual (MSM) | Very confluent rash spread, >40 round and crusted spots on body | MPXV (15 468) | Not suspected | Not done | 11 | Endemic mycoses (eg, sporotrichosis, paracoccidioidomycosis) suspected and received empiric antifungal therapy. Subsequent to mcfDNA sequencing detection of MPXV, history of mpox exposure elicited. Received IV TPOXX following mcfDNA sequencing detection of MPXV with rapid resolution of lesions. Required hospitalization for treatment. Diagnosed with mpox. |
| 9 | 50–59; male | HIV/AIDS (1.8) | Suspected sexual (MSM) | Lesions diffusely present over perianal region, inguinal region, face, forearm, fingers, toes | MPXV (83 199) | Yes | Positive | 20 | Received IV TPOXX. Required hospitalization. Diagnoses included ocular syphilis, bacterial osteomyelitis of thumb, mpox at time of mcfDNA sequencing, on treatment for all; subsequently, also Mycobacterium avium infection yielded from (pulmonary nodule culture). |
| 10c | 40–49; male | HIV/AIDS (44) | Sexual (MSM) | Extensive, progressive perianal/perirectal lesions with resulting rectal stenosis and intestinal obstruction | Alphapapillomavirus 11 (81) HSV-2 (1676) EBV (297) CMV (18 181) HHV-8 (559) MPXV (834 588d) Enterocytozoon bieneusi (7608) |
Yes | Positive | 21 | Received prolonged IV TPOXX. Required hospitalization in ICU. Diagnosed with mpox with complications of GI obstruction, MRSA (PICC line–associated). Subsequently developed septic shock and rapidly died. |
| HHV-8 (103) MPXV (571 364d) Enterocytozoon bieneusi (7608) Escherichia coli (417) Staphylococcus aureus (1526) |
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| 11 | 30–39; male | HIV/AIDS (29) | Unknown | One single lesion on elbow | MPXV (18 052) | Not suspected | Not done (after mcfDNA sequencing detection of MPXV, skin biopsy sample tested by PCR and yielded positive) | 7 or 8, if pulmonary nodules secondary to mpox (being investigated) | Suspected fungal etiology; lesion biopsied with inconclusive dermatological assessment; chest CT demonstrated pulmonary nodules. History of confirmed mpox >6 mo previously with documented resolution of lesions. Diagnosed with mpox and PO TPOXX subsequent to mcfDNA sequencing detection of MPXV. |
| 12 | 40–49; male | HIV/AIDSe | Suspected sexual (MSM) | No reported lesions, although 1 rectal ulcer of unclear etiology | HSV-2 (203) CMV (578) HHV-8 (7376) MPXV (6610) Histoplasma capsulatum (62) Pneumocystis jirovecii (62) |
Not suspected | Not done (after mcfDNA sequencing detection of MPXV, PCR from blind rectal swab performed and yielded negative result) | 0 | Presented with severe pulmonary disease with hemorrhaging; conventional testing positive for Histoplasma. Required hospitalization in ICU. Complete diagnosis unclear but included histoplasmosis, Kaposi sarcoma, PJP, and presumptive mpox (latter 3 subsequent to mcfDNA sequencing detections). Subsequently died from pulmonary complications not thought to be mpox related. |
Abbreviations: CMV, cytomegalovirus; CP, case-patient; CT, computed tomography; EBV, Epstein-Barr virus; GI, gastrointestinal; HHV-8, human herpesvirus 8; HIV, human immunodeficiency virus; HSV-1, herpes simplex virus type 1; HSV-2, herpes simplex virus type 2; ICU, intensive care unit; IV, intravenous; mcfDNA, microbial cell-free DNA; MPM, molecules per microliter; MPXV, Monkeypox virus; MRSA, methicillin-resistant Staphylococcus aureus; MSM, men who have sex with men; PCR, polymerase chain reaction; PICC, peripherally inserted central catheter; PJP, Pneumocystis jirovecii pneumonia; PO, per os (oral); TPOXX, tecovirimat.
aDetections are provided in MPMs except when a specimen did not meet the minimum sequencing coverage requirements and therefore the reported organism(s) could not be quantified as was the case for case-patient 3.
bAdditional relevant clinical and treatment data are provided when available.
cCase-patients 1, 7, and 10 had repeat mcfDNA sequencing on plasma samples obtained approximately 3–4 weeks after the first respective sample.
dConcentration estimate above validated assay range; reported as >316 000.
eCD4 count unavailable for this patient.