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O’Shea J, Zucker J, Stampfer S, Cash-Goldwasser S, Minhaj FS, Dretler A, Cheeley J, Chaudhuri S, Gallitano SM, Gunaratne S, Parkinson M, Epling B, Morcock DR, Sereti I, Deleage C. Prolonged Mpox Disease in People With Advanced HIV: Characterization of Mpox Skin Lesions. J Infect Dis 2024; 229:S243-S248. [PMID: 38019806 PMCID: PMC10965209 DOI: 10.1093/infdis/jiad532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/01/2023] Open
Abstract
We report 3 complicated and prolonged cases of mpox in people with advanced human immunodeficiency virus (HIV) not on antiretroviral therapy (ART) at mpox diagnosis. Multiple medical countermeasures were used, including prolonged tecovirimat treatment and immune optimization with ART initiation. Immunofluorescence of skin biopsies demonstrated a dense immune infiltrate of predominantly myeloid and CD8+ T cells, with a strong type I interferon local response. RNAscope detected abundant replication of monkeypox virus (MPXV) in epithelial cells and dendritic cells. These data suggest that prolonged mpox in people with advanced HIV may be due to ongoing MPXV replication, warranting aggressive medical countermeasures and immune optimization.
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Affiliation(s)
- Jesse O’Shea
- Mpox Emergency Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jason Zucker
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York
| | - Samuel Stampfer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Shama Cash-Goldwasser
- Mpox Emergency Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Faisal S Minhaj
- Mpox Emergency Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexandra Dretler
- Division of Infectious Diseases, Atlanta and Emory Decatur Hospital, Decatur, Georgia
| | - Justin Cheeley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Shaoli Chaudhuri
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York
| | - Stephanie M Gallitano
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York
| | - Shauna Gunaratne
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York
| | - Melissa Parkinson
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York
| | - Brian Epling
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - David R Morcock
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Claire Deleage
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland
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Leonard JB, Minhaj FS, Erickson K, King J. Fomepizole use reported to United States Poison Centers from 2010 to 2021. Clin Toxicol (Phila) 2024; 62:120-125. [PMID: 38465690 DOI: 10.1080/15563650.2024.2319863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/09/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The diagnosis of toxic alcohol poisoning is often based on clinical presentation and nonspecific surrogate laboratory studies due to limited testing availability. Fomepizole is the recommended antidote and often administered empirically. The objective of this study is to identify substances that mimic toxic alcohols and compare key clinical factors between toxic alcohol and non-toxic alcohol exposures when fomepizole was administered. METHODS This study was a retrospective evaluation using the National Poison Data System from January 1, 2010 through December 31, 2021. Exposures were included if fomepizole was administered. Toxic alcohol exposures had ethylene glycol or methanol as a coded substance. For exposures not coded as a toxic alcohol, the first substance was described. Paracetamol (acetaminophen) exposures from 2020 and 2021 were excluded. RESULTS Fomepizole was reportedly used 25,110 times over 12 years. Use increased from 1,955 in 2010 to 2,710 in 2021. Most administrations were for reported toxic alcohol poisoning (60 percent) but use in reported non-toxic alcohol poisoning was greater starting in 2020. Toxic alcohol exposures were older (43.3 versus 39.8 years; P < 0.001) and more likely male (65.7 percent versus 58.2 percent). Level of care was mostly a critical care unit (67.7 percent), which was less common in toxic alcohol (63.3 percent) than non-toxic alcohol exposures (74.2 percent). The most common non-toxic alcohol substances were ethanol (24.9 percent) or an unknown drug (17.5 percent). Acidosis, increased creatinine concentration, anion gap, and osmolal gap, and kidney failure were coded in a lower proportion of toxic alcohol exposures than non-toxic alcohol exposures (P < 0.001). DISCUSSION The inability to provide rapid clinical confirmation of toxic alcohol poisoning results in the empiric administration of fomepizole to many patients who will ultimately have other diagnoses. Although fomepizole is relative well tolerated we estimated that this practice costs between $1.5 to $2.5 million. The major limitations of this work include the biases associated with retrospective record review, and the inability to confirm the exposures which may have resulted in allocation error. CONCLUSION Most fomepizole use was for a presumed toxic alcohol. This recently shifted to greater use in likely non-toxic alcohol poisoning. Key difference between the groups suggest fomepizole administration was likely due to the difficulty in diagnosis of toxic alcohol poisoning along with the efficacy and safety of fomepizole. Increased toxic alcohol laboratory testing availability could improve timely diagnosis, reserving fomepizole use for toxic alcohol poisoning.
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Affiliation(s)
- James B Leonard
- Maryland Poison Center, Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Kennedy Erickson
- Washington State University College of Pharmacy and Pharmaceutical Sciences, Spokane, WA, USA
| | - Joshua King
- Maryland Poison Center, Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
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Minhaj FS, Singh V, Cohen SE, Townsend MB, Scott H, Szumowski J, Hare CB, Upadhyay P, Reddy J, Alexander B, Baird N, Navarra T, Priyamvada L, Wynn N, Carson WC, Odafe S, Guagliardo SAJ, Sims E, Rao AK, Satheshkumar PS, Weidle PJ, Hutson CL. Prevalence of Undiagnosed Monkeypox Virus Infections during Global Mpox Outbreak, United States, June-September 2022. Emerg Infect Dis 2023; 29:2307-2314. [PMID: 37832516 PMCID: PMC10617324 DOI: 10.3201/eid2911.230940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023] Open
Abstract
Since May 2022, mpox has been identified in 108 countries without endemic disease; most cases have been in gay, bisexual, or other men who have sex with men. To determine number of missed cases, we conducted 2 studies during June-September 2022: a prospective serologic survey detecting orthopoxvirus antibodies among men who have sex with men in San Francisco, California, and a retrospective monkeypox virus PCR testing of swab specimens submitted for other infectious disease testing among all patients across the United States. The serosurvey of 225 participants (median age 34 years) detected 18 (8.0%) who were orthopoxvirus IgG positive and 3 (1.3%) who were also orthopoxvirus IgM positive. The retrospective PCR study of 1,196 patients (median age 30 years; 54.8% male) detected 67 (5.6%) specimens positive for monkeypox virus. There are likely few undiagnosed cases of mpox in regions where sexual healthcare is accessible and patient and clinician awareness about mpox is increased.
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Kreuze MA, Minhaj FS, Duwell M, Gigante CM, Kim AM, Crum D, Perlmutter R, Rubin JH, Myers R, Lukula SL, Ravi-Caldwell N, Sockwell D, Chen TH, de Perio MA, Hughes CM, Davidson WB, Wilkins K, Baird N, Lowe D, Li Y, McCollum AM, Blythe D, Rao AK. How did the 2022 global mpox outbreak happen? A travel-associated case 6 months earlier may provide important clues. Travel Med Infect Dis 2023; 55:102618. [PMID: 37506963 DOI: 10.1016/j.tmaid.2023.102618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Molly A Kreuze
- Maryland State Department of Health, USA; Epidemic Intelligence Service, USA.
| | - Faisal S Minhaj
- Epidemic Intelligence Service, USA; Division of High Consequence Pathogens and Pathology, USA
| | | | | | | | - David Crum
- Maryland State Department of Health, USA
| | | | | | | | | | | | | | - Tai-Ho Chen
- Division of Global Migration and Quarantine, USA
| | | | | | | | - Kim Wilkins
- Division of High Consequence Pathogens and Pathology, USA
| | - Nicolle Baird
- Division of High Consequence Pathogens and Pathology, USA; Laboratory Leadership Service, USA
| | - David Lowe
- Division of High Consequence Pathogens and Pathology, USA
| | - Yu Li
- Division of High Consequence Pathogens and Pathology, USA
| | | | | | - Agam K Rao
- Division of High Consequence Pathogens and Pathology, USA
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Beeson A, Styczynski A, Hutson CL, Whitehill F, Angelo KM, Minhaj FS, Morgan C, Ciampaglio K, Reynolds MG, McCollum AM, Guagliardo SAJ. Mpox respiratory transmission: the state of the evidence. Lancet Microbe 2023; 4:e277-e283. [PMID: 36898398 PMCID: PMC9991082 DOI: 10.1016/s2666-5247(23)00034-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 03/09/2023]
Abstract
The relative contribution of the respiratory route to transmission of mpox (formerly known as monkeypox) is unclear. We review the evidence for respiratory transmission of monkeypox virus (MPXV), examining key works from animal models, human outbreaks and case reports, and environmental studies. Laboratory experiments have initiated MPXV infection in animals via respiratory routes. Some animal-to-animal respiratory transmission has been shown in controlled studies, and environmental sampling studies have detected airborne MPXV. Reports from real-life outbreaks demonstrate that transmission is associated with close contact, and although it is difficult to infer the route of MPXV acquisition in individual case reports, so far respiratory transmission has not been specifically implicated. Based on the available evidence, the likelihood of human-to-human MPXV respiratory transmission appears to be low; however, studies should continue to assess this possibility.
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Affiliation(s)
- Amy Beeson
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ashley Styczynski
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christina L Hutson
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florence Whitehill
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kristina M Angelo
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Faisal S Minhaj
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Clint Morgan
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kaitlyn Ciampaglio
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary G Reynolds
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrea M McCollum
- Mpox Response Team, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Rao AK, Schrodt CA, Minhaj FS, Waltenburg MA, Cash-Goldwasser S, Yu Y, Petersen BW, Hutson C, Damon IK. Interim Clinical Treatment Considerations for Severe Manifestations of Mpox - United States, February 2023. MMWR Morb Mortal Wkly Rep 2023; 72:232-243. [PMID: 36862595 PMCID: PMC9997665 DOI: 10.15585/mmwr.mm7209a4] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Monkeypox (mpox) is a disease caused by infection with Monkeypox virus (MPXV), an Orthopoxvirus (OPXV) in the same genus as Variola virus, which causes smallpox. During 2022, a global outbreak involving mpox clade IIb was recognized, primarily among gay, bisexual, and other men who have sex with men.* Most affected patients have been immunocompetent and experienced ≤10 rash lesions (1). CDC has recommended supportive care including pain control.† However, some patients have experienced severe mpox manifestations, including ocular lesions, neurologic complications, myopericarditis, complications associated with mucosal (oral, rectal, genital, and urethral) lesions, and uncontrolled viral spread due to moderate or severe immunocompromise, particularly advanced HIV infection (2). Therapeutic medical countermeasures (MCMs) are Food and Drug Administration (FDA)-regulated drugs and biologics that are predominantly stockpiled by the U.S. government; MCMs developed for smallpox preparedness or shown to be effective against other OPXVs (i.e., tecovirimat, brincidofovir, cidofovir, trifluridine ophthalmic solution, and vaccinia immune globulin intravenous [VIGIV]) have been used to treat severe mpox. During May 2022-January 2023, CDC provided more than 250 U.S. mpox consultations. This report synthesizes data from animal models, MCM use for human cases of related OPXV, unpublished data, input from clinician experts, and experience during consultations (including follow-up) to provide interim clinical treatment considerations. Randomized controlled trials and other carefully controlled research studies are needed to evaluate the effectiveness of MCMs for treating human mpox. Until data gaps are filled, the information presented in this report represents the best available information concerning the effective use of MCMs and should be used to guide decisions about MCM use for mpox patients.
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Blackburn D, Minhaj FS, Al Hammoud R, Orciari L, Miller J, Maness T, Stewart J, Singletary B, Ledezma E, Ellsworth M, Carlo-Angleró A, Niezgoda M, Gigante CM, Rao AK, Satheshkumar PS, Heresi GP, Kieffer A, Wallace RM. Human Rabies - Texas, 2021. MMWR Morb Mortal Wkly Rep 2022; 71:1547-1549. [PMID: 36480462 PMCID: PMC9762899 DOI: 10.15585/mmwr.mm7149a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In late August 2021, a boy aged 7 years was bitten by a bat while he was playing outside his apartment home in Medina County, Texas. He informed his parents; however, no rabies postexposure prophylaxis (PEP) was sought because there were no visible bite marks, and the family was unaware that contact with a bat, including in the absence of visible bite marks, might cause rabies. Approximately 2 months later, the child was hospitalized for altered mental status, seizures, and hypersalivation and ultimately received a diagnosis of rabies. Experimental therapies were attempted; however, the child died 22 days after symptom onset. Fifty-seven persons who met criteria for suspected or known exposure to infectious secretions in this case were advised to consult with a medical provider about the need for rabies PEP in accordance with Advisory Committee on Immunization Practices (ACIP) guidelines (1). Rabies, an acute, progressive neuroencephalitis, is nearly always fatal. Although dogs are the most common source of human rabies deaths worldwide and account for an estimated 59,000 annual cases of human rabies globally (2), bats are the most common source of domestically acquired rabies in the United States and have been implicated in 31 (81.6%) of 38 human infections since 2000 (3). Attempts to prevent death or poor neurologic outcomes once rabies symptoms develop have been largely unsuccessful (4). Administration of rabies PEP, comprising rabies immunoglobulin and a series of doses of rabies vaccine, is critical to preventing rabies after an exposure; enhanced public education about the risk posed by bats, and the availability of PEP to prevent rabies, is needed.
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Hennessee I, Shelus V, McArdle CE, Wolf M, Schatzman S, Carpenter A, Minhaj FS, Petras JK, Cash-Goldwasser S, Maloney M, Sosa L, Jones SA, Mangla AT, Harold RE, Beverley J, Saunders KE, Adams JN, Stanek DR, Feldpausch A, Pavlick J, Cahill M, O’Dell V, Kim M, Alarcón J, Finn LE, Goss M, Duwell M, Crum DA, Williams TW, Hansen K, Heddy M, Mallory K, McDermott D, Cuadera MKQ, Adler E, Lee EH, Shinall A, Thomas C, Ricketts EK, Koonce T, Rynk DB, Cogswell K, McLafferty M, Perella D, Stockdale C, Dell B, Roskosky M, White SL, Davis KR, Milleron RS, Mackey S, Barringer LA, Bruce H, Barrett D, D’Angeli M, Kocharian A, Klos R, Dawson P, Ellington SR, Mayer O, Godfred-Cato S, Labuda SM, McCormick DW, McCollum AM, Rao AK, Salzer JS, Kimball A, Gold JAW. Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox - United States, May 17-September 24, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1407-1411. [PMID: 36331124 PMCID: PMC9639439 DOI: 10.15585/mmwr.mm7144a4] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17–September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,† primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0–12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13–17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)–level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.
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Miller MJ, Cash-Goldwasser S, Marx GE, Schrodt CA, Kimball A, Padgett K, Noe RS, McCormick DW, Wong JM, Labuda SM, Borah BF, Zulu I, Asif A, Kaur G, McNicholl JM, Kourtis A, Tadros A, Reagan-Steiner S, Ritter JM, Yu Y, Yu P, Clinton R, Parker C, Click ES, Salzer JS, McCollum AM, Petersen B, Minhaj FS, Brown E, Fischer MP, Atmar RL, DiNardo AR, Xu Y, Brown C, Goodman JC, Holloman A, Gallardo J, Siatecka H, Huffman G, Powell J, Alapat P, Sarkar P, Hanania NA, Bruck O, Brass SD, Mehta A, Dretler AW, Feldpausch A, Pavlick J, Spencer H, Ghinai I, Black SR, Hernandez-Guarin LN, Won SY, Shankaran S, Simms AT, Alarcón J, O’Shea JG, Brooks JT, McQuiston J, Honein MA, O’Connor SM, Chatham-Stephens K, O’Laughlin K, Rao AK, Raizes E, Gold JAW, Morris SB, Duessel S, Danaie D, Hickman A, Griffith B, Sanneh H, Hutchins H, Phyathep C, Carpenter A, Shelus V, Petras J, Hennessee I, Davis M, McArdle C, Dawson P, Gutelius B, Bisgard K, Wong K, Galang RR, Perkins KM, Filardo TD, Davidson W, Hutson C, Lowe D, Zucker JE, Wheeler DA, He L, Jain AK, Semeniuk O, Chatterji D, McClure M, Li LX, Mata J, Beselman S, Cross SL, Menzies B, Keller M, Chaturvedi V, Thet A, Carroll R, Hebert C, Patel G, Gandhi V, Abrams-Downey A, Nawab M, Landon E, Lee G, Kaplan-Lewis E, Miranda C, Carmack AE, Traver EC, Lazarte S, Perl TM, Chow J, Kitchell E, Nijhawan A, Habib O, Bernus A, Andujar G, Davar K, Holtom P, Wald-Dickler N, Lorio MA, Gaviria J, Chu V, Wolfe CR, McKellar MS, Farran S, Diaz Wong RA, Schliep T, Shaw R, Tebas P, Richterman A, Aurelius M, Peterson L, Trible R, Rehman T, Sabzwari R, Hines E, Birkey T, Stokich D, King J, Farabi A, Jenny-Avital E, Touleyrou L, Sandhu A, Newman G, Bhamidipati D, Bhamidipati D, Vigil K, Caro M, Banowski K, Chinyadza TW, Rosenzweig J, Jones MS, Camargo JF, Marsh KJ, Liu EW, Guerrero-Wooley R, Pottinger P. Severe Monkeypox in Hospitalized Patients - United States, August 10-October 10, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1412-1417. [PMID: 36327164 PMCID: PMC9639440 DOI: 10.15585/mmwr.mm7144e1] [Citation(s) in RCA: 94] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
As of October 21, 2022, a total of 27,884 monkeypox cases (confirmed and probable) have been reported in the United States.§ Gay, bisexual, and other men who have sex with men have constituted a majority of cases, and persons with HIV infection and those from racial and ethnic minority groups have been disproportionately affected (1,2). During previous monkeypox outbreaks, severe manifestations of disease and poor outcomes have been reported among persons with HIV infection, particularly those with AIDS (3-5). This report summarizes findings from CDC clinical consultations provided for 57 patients aged ≥18 years who were hospitalized with severe manifestations of monkeypox¶ during August 10-October 10, 2022, and highlights three clinically representative cases. Overall, 47 (82%) patients had HIV infection, four (9%) of whom were receiving antiretroviral therapy (ART) before monkeypox diagnosis. Most patients were male (95%) and 68% were non-Hispanic Black (Black). Overall, 17 (30%) patients received intensive care unit (ICU)-level care, and 12 (21%) have died. As of this report, monkeypox was a cause of death or contributing factor in five of these deaths; six deaths remain under investigation to determine whether monkeypox was a causal or contributing factor; and in one death, monkeypox was not a cause or contributing factor.** Health care providers and public health professionals should be aware that severe morbidity and mortality associated with monkeypox have been observed during the current outbreak in the United States (6,7), particularly among highly immunocompromised persons. Providers should test all sexually active patients with suspected monkeypox for HIV at the time of monkeypox testing unless a patient is already known to have HIV infection. Providers should consider early commencement and extended duration of monkeypox-directed therapy†† in highly immunocompromised patients with suspected or laboratory-diagnosed monkeypox.§§ Engaging all persons with HIV in sustained care remains a critical public health priority.
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Minhaj FS, Petras JK, Brown JA, Mangla AT, Russo K, Willut C, Lee M, Beverley J, Harold R, Milroy L, Pope B, Gould E, Beeler C, Schneider J, Mostafa HH, Godfred-Cato S, Click ES, Borah BF, Galang RR, Cash-Goldwasser S, Wong JM, McCormick DW, Yu PA, Shelus V, Carpenter A, Schatzman S, Lowe D, Townsend MB, Davidson W, Wynn NT, Satheshkumar PS, O'Connor SM, O'Laughlin K, Rao AK, McCollum AM, Negrón ME, Hutson CL, Salzer JS. Orthopoxvirus Testing Challenges for Persons in Populations at Low Risk or Without Known Epidemiologic Link to Monkeypox — United States, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1155-1158. [PMID: 36074752 PMCID: PMC9470221 DOI: 10.15585/mmwr.mm7136e1] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pfeiffer JA, Collingwood A, Rider LE, Minhaj FS, Matheny AM, Kling C, McCollum AM, Nolen LD, Morgan CN. High-Contact Object and Surface Contamination in a Household of Persons with Monkeypox Virus Infection — Utah, June 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1092-1094. [PMID: 36006842 PMCID: PMC9422960 DOI: 10.15585/mmwr.mm7134e1] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Minhaj FS, Ogale YP, Whitehill F, Schultz J, Foote M, Davidson W, Hughes CM, Wilkins K, Bachmann L, Chatelain R, Donnelly MA, Mendoza R, Downes BL, Roskosky M, Barnes M, Gallagher GR, Basgoz N, Ruiz V, Kyaw NTT, Feldpausch A, Valderrama A, Alvarado-Ramy F, Dowell CH, Chow CC, Li Y, Quilter L, Brooks J, Daskalakis DC, McClung RP, Petersen BW, Damon I, Hutson C, McQuiston J, Rao AK, Belay E, McCollum AM. Monkeypox Outbreak - Nine States, May 2022. MMWR Morb Mortal Wkly Rep 2022; 71:764-769. [PMID: 35679181 PMCID: PMC9181052 DOI: 10.15585/mmwr.mm7123e1] [Citation(s) in RCA: 171] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories,† none of which has endemic monkeypox, have reported laboratory-confirmed cases. On May 17, CDC, in coordination with state and local jurisdictions, initiated an emergency response to identify, monitor, and investigate additional monkeypox cases in the United States. This response has included releasing a Health Alert Network (HAN) Health Advisory, developing interim public health and clinical recommendations, releasing guidance for LRN testing, hosting clinician and public health partner outreach calls, disseminating health communication messages to the public, developing protocols for use and release of medical countermeasures, and facilitating delivery of vaccine postexposure prophylaxis (PEP) and antivirals that have been stockpiled by the U.S. government for preparedness and response purposes. On May 19, a call center was established to provide guidance to states for the evaluation of possible cases of monkeypox, including recommendations for clinical diagnosis and orthopoxvirus testing. The call center also gathers information about possible cases to identify interjurisdictional linkages. As of May 31, this investigation has identified 17§ cases in the United States; most cases (16) were diagnosed in persons who identify as gay, bisexual, or men who have sex with men (MSM). Ongoing investigation suggests person-to-person community transmission, and CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread. Public health authorities are identifying cases and conducting investigations to determine possible sources and prevent further spread. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.¶.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Monkeypox Response Team 2022
- Epidemic Intelligence Service, CDC; Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC; Massachusetts Department of Public Health; New York City Department of Health and Mental Hygiene, New York, New York; Salt Lake County Health Department, Salt Lake City, Utah; Florida Department of Health; Fairfax County Health Department, Fairfax, Virginia; Public Health - Seattle & King County, Seattle, Washington; Colorado Department of Public Health and Environment; Massachusetts General Hospital, Boston Massachusetts; Georgia Department of Health; Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC; Division of Global Migration and Quarantine, National Center of Emerging Zoonotic Infectious Diseases, CDC; National Institute for Occupational Safety and Health; Division of Global Health Protection, Center for Global Health, CDC; Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC
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Acquisto NM, Uttaro E, Debona D, Minhaj FS. Assessment of rabies immune globulin dose rounding at a university health system. Am J Emerg Med 2022; 58:141-147. [DOI: 10.1016/j.ajem.2022.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022] Open
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Wallace M, Moulia D, Blain AE, Ricketts EK, Minhaj FS, Link-Gelles R, Curran KG, Hadler SC, Asif A, Godfrey M, Hall E, Fiore A, Meyer S, Su JR, Weintraub E, Oster ME, Shimabukuro TT, Campos-Outcalt D, Morgan RL, Bell BP, Brooks O, Talbot HK, Lee GM, Daley MF, Oliver SE. The Advisory Committee on Immunization Practices' Recommendation for Use of Moderna COVID-19 Vaccine in Adults Aged ≥18 Years and Considerations for Extended Intervals for Administration of Primary Series Doses of mRNA COVID-19 Vaccines - United States, February 2022. MMWR Morb Mortal Wkly Rep 2022; 71:416-421. [PMID: 35298454 PMCID: PMC8942305 DOI: 10.15585/mmwr.mm7111a4] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kunkel A, Minhaj FS, Whitehill F, Austin C, Hahn C, Kieffer AJ, Mendez L, Miller J, Tengelsen LA, Gigante CM, Orciari LA, Rao AK, Wallace RM. Notes from the Field: Three Human Rabies Deaths Attributed to Bat Exposures - United States, August 2021. MMWR Morb Mortal Wkly Rep 2022; 71:31-32. [PMID: 34990442 PMCID: PMC8735561 DOI: 10.15585/mmwr.mm7101a5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leonard JB, Minhaj FS, Paterson E, Klein-Schwartz W. Exposures in pregnant patients reported to United States Poison Centers. Clin Toxicol (Phila) 2021; 60:356-361. [PMID: 34406096 DOI: 10.1080/15563650.2021.1968420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Limited data describe poisoning exposures in pregnant women. Previous studies are limited to inpatient populations, those seen only by toxicologists, or single poison centers. This study aimed to describe poison exposures reported to U.S. poison control centers in pregnant patients compared to non-pregnant controls. METHODS This was a retrospective observational study of exposures reported to the American Association of Poison Control Centers National Poison Data System from 2000 through 2019. Pregnant patients were included from 15-44 years along with a random sampling of 5:1 age and year matched control group of non-pregnant exposures. Demographics, primary substance, and known medical outcomes were described. Chi square analysis was performed for comparisons. RESULTS From 2000 to 2019, a total of 131,619 pregnant cases and 658,095 non-pregnant controls were identified. The median age was 27 years (IQR: 22, 31) for the matched groups. For known trimester of pregnancy: 29.8, 37.0, and 28.2% were in the first, second, and third trimester, respectively. Most common exposures were analgesics and cleaning products. Intentional exposures were more common in non-pregnant compared to pregnant cases (41.2 vs 21.9%; OR 2.71, 95% CI 2.67-2.75), mostly self-harm attempts (31.5 vs. 15.8%). Notably, there was a large discrepancy in the proportion of environmental exposures, with fewer in non-pregnant controls compared with pregnant cases (3.8 vs. 12.1%; OR 0.29, 95% CI 0.28-0.29). More non-pregnant cases had multiple substance exposures compared with pregnant cases (22.2 vs. 10.9%; OR 2.34, 95% CI 2.29-2.38). There were more moderate effect outcomes in non-pregnant compared with pregnant cases (13.2 vs. 6.3%; OR 2.25, 95% CI 2.20-2.30). CONCLUSIONS Outcomes of poisoning exposures in pregnant patients reported to U.S. poison centers are less serious compared to non-pregnant controls, likely due to the lower rates of intentional abuse and self-harm exposures and greater number of minimally toxic environmental exposures.
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Affiliation(s)
- James B Leonard
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Faisal S Minhaj
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Emily Paterson
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Minhaj FS, Leonard JB. A description of the clinical course of severe benzonatate poisonings reported in the literature and to NPDS: A systematic review supplemented with NPDS cases. Hum Exp Toxicol 2021; 40:S39-S48. [PMID: 34219543 DOI: 10.1177/09603271211030560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Benzonatate is a commonly prescribed medication that can be lethal in acute overdose of a small number of capsules. OBJECTIVE This was a systematic review to describe the course of severe poisoning and deaths from benzonatate supplemented with the National Poison Data System (NPDS) fatalities module. METHODS The NPDS was queried from 2000 to 2018 for benzonatate fatalities. Pubmed, Cochrane, Embase, and Google Scholar were searched for combinations of benzonatate and "poisoning," "overdose," and "toxicity." References of relevant articles were searched for additional publications. Articles were included if they described the clinical course of at least one patient suffering from benzonatate poisoning and available in English. Dual independent review and extraction were performed. RESULTS Seventeen cases from NPDS and 19 published reports met the inclusion criteria resulting in 36 cases, mostly (28/36) self-harm ingestions. Most patients were young [17 (11-29), median (IQR)] and female (22). Onset of toxicity was rapid at <5 min (9). Most common symptoms included cardiac arrest (29), seizures (24), and dysrhythmias (24). Treatments included intubation (26), cardiopulmonary resuscitation (28), vasopressors (20) and others. Return of spontaneous circulation was achieved in 23/28 patients, but most had significant neurologic deficits or other end organ damage and 5 survived with a good neurologic outcome. CONCLUSION AND RELEVANCE Overdose ingestions of benzonatate can cause significant toxicity with a rapid onset. Interventions performed were generally supportive in nature. Duration of directly toxic effects is short, but dramatic with neurologic devastation and resuscitated patients often still have a poor outcome.
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Affiliation(s)
- F S Minhaj
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - J B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Abstract
OBJECTIVE This is a descriptive study evaluating fatal iatrogenic and in-hospital medication errors reported to United States poison centers. METHODS A retrospective evaluation of the National Poison Data System from 2000-2017 of all therapeutic errors with a scenario coded as iatrogenic/healthcare professional or occurring in a healthcare facility. Death abstracts were reviewed for details of the exposure and therapeutic error scenarios were recoded or added to the case as appropriate. Cases, where death was considered not related to the exposure, were excluded. Additionally, we created one additional scenario (rate-related) and one additional route of administration (intrathecal) to better describe the cases. RESULTS A total of 172 cases were evaluated. The majority of the patients were female (52.3%) with a median age of 58.5 years (range: 2 days to 96 years). The most commonly reported medication error was "other incorrect dose" (22.7%) followed by other/unknown error (15.1%). The route of exposure was primarily parenteral (54.9%), followed by ingestion (30.2%), then intrathecal (7.0%). The most common medications were cardiac drugs, chemotherapeutics, opioids, anticoagulants, and sedative-hypnotic/antipsychotics. CONCLUSIONS Iatrogenic and in-hospital medication errors have been studied extensively with goals to reduce their occurrence. Specific controls to prevent incorrect dosing routes, 10-fold overdoses, and incorrect intrathecal administration have been instituted. Despite interventions, all three of these therapeutic errors continued to occur in 2017, suggesting that more preventive controls should be instituted.
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Affiliation(s)
- James B Leonard
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Faisal S Minhaj
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Minhaj FS, Schult RF, Fields A, Wiegand TJ. A Case of Nebulized Naloxone Use With Confirmatory Serum Naloxone Concentrations. Ann Pharmacother 2018; 52:495-496. [PMID: 29319329 DOI: 10.1177/1060028017752428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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