Mpox in HIV-positive patients: A retrospective case series from Saudi Arabia highlighting clinical characteristics and outcomes

BACKGROUND: Mpox has re-emerged globally since 2022, disproportionately affecting people living with HIV (PLHIV). While infection in immunocompetent individuals is usually mild and self-limited, severe and occasionally fatal disease has been reported among individuals with advanced immunosuppression. Regional data describing mpox-HIV coinfection in the Middle East remain limited. METHODS: We conducted a retrospective descriptive case series at a tertiary care center in Riyadh, Saudi Arabia. Adults diagnosed with laboratory-confirmed mpox and newly identified HIV infection between July 2022 and May 2024 were included. Demographic characteristics, clinical manifestations, immunological parameters, management strategies, and outcomes were extracted from electronic medical records and analyzed descriptively. RESULTS: Four male patients were identified, with a median age of 38.3 years. All presented with mucocutaneous disease, most commonly involving the genital or perianal region, accompanied by systemic symptoms such as fever and lymphadenopathy. Two patients had concurrent reactive syphilis serology. Three individuals with preserved immune function (CD4 ≥500 cells/mm³) experienced mild-to-moderate disease and achieved full recovery with supportive care and timely initiation of antiretroviral therapy (ART). In contrast, one patient with advanced immunosuppression (CD4 110 cells/mm³) developed rapidly progressive systemic illness with necrotizing myopathy-like involvement and rhabdomyolysis, requiring intensive care admission, and died despite antimicrobial therapy and delayed initiation of antiviral and antiretroviral treatment. CONCLUSIONS: This case series describes the clinical spectrum of mpox among PLHIV in Saudi Arabia and demonstrates substantial variability in disease severity according to immune status. The frequent presence of concurrent sexually transmitted infections highlights the importance of integrated sexual health screening. These findings emphasize the need for early HIV diagnosis, prompt initiation of antiretroviral therapy, and close clinical monitoring of immunocompromised individuals presenting with mpox.