Mpox, HIV, and a Compounding Sepsis Crisis in Africa

Mpox, a zoonotic disease caused by the monkeypox virus (MPXV), has reemerged as a significant global public health threat, particularly in sub-Saharan Africa, where more than 50,000 cases have been reported since 2022. Although HIV-related immunosuppression is a known risk factor for severe MPXV infection, the intersection of mpox, HIV, and critical illness has been largely overlooked in ongoing outbreaks in East and Central Africa. We describe a case of a 45-year-old woman in Uganda, living with WHO stage 3 HIV and active pulmonary tuberculosis (TB), who developed mpox-associated sepsis and acute hypoxemic respiratory failure. One month after initial mpox diagnosis and receipt of supportive care, she developed high fever, hypotension, and hypoxemia and was hospitalized. Painful oropharyngeal and mucocutaneous lesions limited her adherence to oral antiretroviral and anti-TB therapy. Despite oxygen therapy, judicious fluid resuscitation, and empiric antibiotics, the patient deteriorated rapidly and died on hospital day two. This case illustrates the emerging burden of mpox-related critical illness in persons living with HIV in sub-Saharan Africa. In this context, we propose key actions to improve the international mpox response, focusing on the clinical management of mpox-associated sepsis and critical illness.