Severe complication of monkeypox reported to the US CDC: risks associated with HIV and other causes of immunosuppression

Simon Collins, HIV i-Base

Most cases in the current monkeypox (MPX) outbreak have been upsetting, difficult and are commonly painful, but still generally resolve within 2 to 4 weeks.

But there have been reports of extremely serious cases, including penile necrosis, amputation, the need for intensive care and approximately 30 deaths.

To highlight the range and severity of complications, the US CDC issued a health alert of cases that had been reported to them until September 2022. [1]

The alert has particular concerns for people with significant immunosuppression related to HIV and other conditions, especially with low CD4 counts. However, severe cases are also reported in people who are HIV negative.

Examples of severe complications included but were not limited to the following conditions.

  • Atypical or persistent rash with coalescing or necrotic lesions, or both, some which have required extensive surgical debridement or amputation of an affected extremity.
  • Lesions on a significant proportion of the total body surface area, which may be associated with oedema and secondary bacterial or fungal infections among other complications.
  • Lesions in sensitive areas (including mucosal surfaces such as, oropharynx, urethra, rectum, vagina) resulting in severe pain that interferes with activities of daily living.
  • Bowel lesions that are exudative or cause significant tissue oedema, leading to obstruction.
  • Severe lymphadenopathy that can be necrotising or obstructing (such as in airways).
  • Lesions leading to stricture and scar formation resulting in significant morbidity such as urethral and bowel strictures, phimosis, and facial scarring.
  • Involvement of multiple organ systems and associated comorbidities, including:
    –   Oropharyngeal lesions inhibiting oral intake.
    –   Pulmonary involvement with nodular lesions.
    –   Neurologic conditions including encephalitis and transverse myelitis.
    –   Cardiac complications including myocarditis and pericardial disease.
    –   Ocular conditions including severe conjunctivitis and sight-threatening corneal ulcerations.
    –   Urologic involvement including urethritis and penile necrosis.


Several reports to the MMWR include more details on neurological and ocular complications, including in people living with HIV with very low CD4 counts, sometimes not on ART. [2. 3]

Neurological complications are also reviewed in a paper in JAMA. [4]

Shortly after this report was first published, two MPX-related deaths were reported from New York, in people who were immunocompromised or who had other underlying health conditions. [5]

This shows the urgency of comprehensive vaccination programmes that produce optimum protection, however many shots are shown to be needed.


  1. US CDC Health Advisory. Severe Manifestations of Monkeypox among People who are Immunocompromised Due to HIV or Other Conditions. (29 September 2022).
  2. Pastula DM et al. Two cases of monkeypox-associated encephalomyelitis — Colorado and the District of Columbia, July–August 2022. MMWR Morb Mortal Wkly Rep 2022;71:1212–1215.
  3. Cash-Goldwasser S et al. Ocular monkeypox — United States, July–September 2022. MMWR Morb Mortal Wkly Rep. ePub: 17 October 2022. DOI: 10.15585/mmwr.mm7142e1.
  4. Billioux J et al. Neurologic complications of smallpox and monkeypox A review. JAMA Neurol. doi: 10.1001/jamaneurol.2022.3491. (20 September 2022).
  5. NBC news. NYC Announces First 2 Monkeypox-Linked Deaths — and Gives Virus a New Acronym. (21 October 2022).

Links to other websites are current at date of posting but not maintained.