Severe Clade I (subclade Ib) mpox in advanced HIV complicated by multidrug-resistant bacterial superinfection and ocular involvement: a case report from Uganda

BACKGROUND: Mpox in people living with HIV (PLHIV) with advanced immunosuppression is poorly understood in sub-Saharan Africa, where high HIV prevalence intersects with limited access to mpox-specific antivirals. Urgent evidence is needed to guide clinical management and improve outcomes for this vulnerable population in resource-limited settings with outbreaks. CASE PRESENTATION: We report a 30-year-old Ugandan man with advanced HIV (CD4 55 cells/µL, HIV-1 RNA 645,000 copies/mL) who presented with 2 weeks of widespread mucocutaneous disease, circumferential necrotic penile ulceration with severe dysuria, and periocular involvement. Mpox was confirmed by real-time PCR from multiple anatomical sites, with sequencing identifying Clade I (subclade Ib) infection. Longitudinal sampling showed consistently low Ct values in skin and genital lesions despite rising salivary Ct values, indicating differential compartmental viral clearance. Serial pus cultures from ulcerated lesions yielded multi-resistant gram-negative bacilli and coagulase-negative staphylococci, with sustained resistance to first-line agents throughout the clinical course. Meropenem remained the only antimicrobial to which isolates were consistently susceptible across all sampling points, suggestive of evolving polymicrobial wound colonisation under antibiotic selection pressure. MANAGEMENT AND OUTCOME: Empirical ceftriaxone and metronidazole proved ineffective. Culture-guided escalation to intravenous meropenem, along with intensive wound care, pain management, ocular prophylaxis, and resumption of antiretroviral therapy (ART), resulted in gradual clinical improvement. The patient was discharged after 4 weeks with healed skin lesions and mild residual ocular discomfort. At 3 months, immune reconstitution was observed (CD4 173 cells/µL; HIV-1 RNA 72 copies/mL) with complete functional recovery. CONCLUSIONS: Severe Clade Ib (subclade Ib) mpox in advanced HIV can present with genital necrosis, ocular involvement, persistent lesion-site viral burden, and multidrug-resistant bacterial superinfection. Even in the absence of specific antivirals, favourable outcomes can be achieved through integrated HIV care, early culture-guided antimicrobial stewardship, and proactive ocular management.