Disseminated Mpox Infection in a Vaccinated Kidney Transplant Recipient

Introduction: Mpox is a zoonotic orthopoxvirus infection that has recently seen a resurgence worldwide. This is of particular importance in immunocompromised patients. Although Jynneos (live smallpox and mpox vaccine) was shown to be effective in patients with an intact immune system, its effectiveness in immunocompromised patients remains unknown. Case Description: Patient is a 48 year old man with HIV and ESRD who is 8 months post second kidney transplant at presentation. He had diffuse, painful vesiculopustular lesions on skin, oropharynx and rectum following a high risk sexual encounter one month prior to presentation. He was on a belatacept-based immunosuppressive regimen and has received Jynneos approximately two years prior to symptom onset. PCR testing of a cutaneous lesion confirmed mpox clade II. Given the severity of his lesions, he was treated with IV tecovirimat, vaccinia immune globulin (VIVIg), brincidofovir and topical cidofovir. Belatacept was discontinued and mycophenolate dose reduced. His lesions improved and he was discharged after 10 days. Discussion: This report highlights the susceptibility that transplant recipients have to severe mpox infection despite prior vaccination history. Additional studies are needed to assess the effectiveness of these vaccines in immunocompromised patients.Figure 1: Perioral lesions before treatment (A) and after treatment ~2 months later (B), abdomen (C), right hand (D), and back lesions with typical desquamation (E)