Severe Monkeypox in Hospitalized Patients

United States, August 10-October 10, 2022

Maureen J. Miller, MD; Shama Cash-Goldwasser, MD; Grace E. Marx, MD; Caroline A. Schrodt, MD; Anne Kimball, MD; Kia Padgett, MPH; Rebecca S. Noe, MPH; David W. McCormick, MD; Joshua M. Wong, MD; Sarah M. Labuda, MD; Brian F. Borah, MD; Isaac Zulu, MD; Amimah Asif, MBBS; Gurpreet Kaur, MD; Janet M. McNicholl, MD; Athena Kourtis, MD; Andrew Tadros, MD, PhD; Sarah Reagan-Steiner, MD; Jana M. Ritter, DVM; Yon Yu, PharmD; Patricia Yu, MPH; Rachel Clinton, MS; Corrine Parker, PharmD; Eleanor S. Click, MD, PhD; Johanna S. Salzer, DVM; Andrea M. McCollum, PhD; Brett Petersen, MD; Faisal S. Minhaj, PharmD; Ericka Brown, MD; Michael P. Fischer, MD; Robert L. Atmar, MD; Andrew R. DiNardo, MD; Ya Xu, MD, PhD; Cameron Brown, PhD; Jerry Clay Goodman, MD; Ashley Holloman, MD; Julia Gallardo, MD; Hanna Siatecka, MD; Georgia Huffman, MD; John Powell, MD; Philip Alapat, MD; Pralay Sarkar, MD; Nicola A. Hanania, MD; Or Bruck, MD; Steven D. Brass, MD; Aneesh Mehta, MD; Alexandra W. Dretler, MD; Amanda Feldpausch, DVM; Jessica Pavlick, DrPH; Hillary Spencer, MD; Isaac Ghinai, MBBS; Stephanie R. Black, MD; Laura N. Hernandez-Guarin, MD; Sarah Y. Won, MD; Shivanjali Shankaran, MD; Andrew T. Simms, MD; Jemma Alarcón, MD; Jesse G. O'Shea, MD; John T. Brooks, MD; Jennifer McQuiston, DVM; Margaret A. Honein, PhD; Siobhán M. O'Connor, MD; Kevin Chatham-Stephens, MD; Kevin O'Laughlin, MD; Agam K. Rao, MD; Elliot Raizes, MD; Jeremy A. W. Gold, MD; Sapna Bamrah Morris, MD


Morbidity and Mortality Weekly Report. 2022;71(44):1412-1417. 

In This Article

Abstract and Introduction


As of October 21, 2022, a total of 27,884 monkeypox cases (confirmed and probable) have been reported in the United States.§ Gay, bisexual, and other men who have sex with men have constituted a majority of cases, and persons with HIV infection and those from racial and ethnic minority groups have been disproportionately affected.[1,2] During previous monkeypox outbreaks, severe manifestations of disease and poor outcomes have been reported among persons with HIV infection, particularly those with AIDS.[3–5] This report summarizes findings from CDC clinical consultations provided for 57 patients aged ≥18 years who were hospitalized with severe manifestations of monkeypox during August 10–October 10, 2022, and highlights three clinically representative cases. Overall, 47 (82%) patients had HIV infection, four (9%) of whom were receiving antiretroviral therapy (ART) before monkeypox diagnosis. Most patients were male (95%) and 68% were non-Hispanic Black (Black). Overall, 17 (30%) patients received intensive care unit (ICU)–level care, and 12 (21%) have died. As of this report, monkeypox was a cause of death or contributing factor in five of these deaths; six deaths remain under investigation to determine whether monkeypox was a causal or contributing factor; and in one death, monkeypox was not a cause or contributing factor.** Health care providers and public health professionals should be aware that severe morbidity and mortality associated with monkeypox have been observed during the current outbreak in the United States,[6,7] particularly among highly immunocompromised persons. Providers should test all sexually active patients with suspected monkeypox for HIV at the time of monkeypox testing unless a patient is already known to have HIV infection. Providers should consider early commencement and extended duration of monkeypox-directed therapy†† in highly immunocompromised patients with suspected or laboratory-diagnosed monkeypox.§§ Engaging all persons with HIV in sustained care remains a critical public health priority.

During the ongoing monkeypox outbreak, CDC has provided consultation upon request to jurisdictions and clinicians treating patients with monkeypox.¶¶ This report describes the patients from these consultations who were aged ≥18 years and were hospitalized with probable or confirmed monkeypox during August 10–October 10, 2022; the report includes detailed histories for three patients who experienced severe manifestations of monkeypox. CDC obtained data on patient demographic characteristics, clinical course, and outcomes during consultation with health departments or providers. Patient permission for the use of clinical images was obtained. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.***

During August 10–October 10, 2022, CDC provided consultation for 57 patients aged ≥18 years who were hospitalized with severe manifestations of monkeypox (Table 1). Among 57 patients, 54 (95%) were male, and the median age was 34 years (range = 20–61 years). Forty-seven (82%) had HIV infection; among these patients, 31 (72%) of 43 with a known CD4 count had <50 CD4 cells/mm3 (Table 2). Two patients (4%), one of whom had HIV infection, were undergoing chemotherapy for a hematologic malignancy, three (5%) were solid organ transplant recipients, and three (5%) were pregnant. Overall, most patients were Black (68%), and 13 (23%) were experiencing homelessness.†††

All patients had severe dermatologic manifestations, and 39 (68%) also had severe mucosal lesions (Table 1). Some experienced involvement of other organs, including the lungs (12, 21%), eyes (12, 21%), and brain or spinal cord (four, 7%). Overall, 53 (93%) patients received oral tecovirimat, and 37 (65%) received intravenous tecovirimat; 29 (51%) patients received vaccinia immune globulin intravenous (VIGIV),§§§ and 13 (23%) received intravenous cidofovir. All patients who received cidofovir or VIGIV also received tecovirimat. Seventeen (30%) patients received ICU-level care and 12 (21%) died: monkeypox was a cause of death or contributing factor in five of these cases, six deaths remain under investigation to determine whether monkeypox was a causal or contributing factor, and in one death, monkeypox was not a cause or contributing factor.

A list of severe manifestations of monkeypox can be found at
**During the study period and as of October 21, 2022, CDC was notified by state and local jurisdictions of five decedents whose death certificates included monkeypox as a cause of death or contributing factor, six decedents whose cause of death is still under active investigation, and one decedent in whom the death was not monkeypox-related. Additional monkeypox cases involving severe disease or death might not be included in this report if CDC has not yet been notified about the case or if the case occurred outside of the study period.
¶¶CDC offers a monkeypox clinical consultation service for the ongoing monkeypox outbreak. Health care providers seeking additional clinical guidance can contact the CDC Emergency Operations by phone (770-488-7100) or by email (
***45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
†††Homelessness was defined by the clinician caring for the patient and included the experience of both sheltered and unsheltered homelessness.
§§§Tecovirimat, an FDA-approved treatment for smallpox, demonstrated efficacy against monkeypox in animal studies. Interim CDC guidance currently recommends that tecovirimat be considered in patients with severe monkeypox, those at high risk for severe disease, or those whose infection involves anatomic areas where monkeypox virus infection might constitute a special hazard (e.g., the eyes, pharynx, genitals, or anus). VIGIV has been used to treat complications from vaccinia vaccination. CDC holds an expanded access investigative new drug protocol that allows the use of VIGIV for the treatment of orthopoxviruses (including monkeypox) in an outbreak.