Introduction:

Mpox in PLHIV is associated with severe outcomes, particularly when co-infected with opportunistic pathogens, such as Mycobacterium tuberculosis (MTB).

Aim: We describe three cases of severe mpox in PLHIV, each with CD4 counts under 200 cells/mm3 and laboratory-confirmed disseminated tuberculosis.

Methods:

A retrospective review of three hospitalized patients with mpox and HIV who were also found to have disseminated tuberculosis. The clinical course, management, and outcomes were summarized.

Results:

Case 1: A 44-year-old man with newly diagnosed HIV presented after 14 days of illness with disseminated necrotizing mpox and sepsis, along with severe immunosuppression (CD4 <200 cells/mm3). Urine LF-LAM confirmed disseminated TB, and blood culture confirmed Staphylococcus aureus bacteremia. Despite oxygen supplementation and broad-spectrum antibiotics, he died within three days of admission, prior to starting anti-tuberculosis or antiretroviral therapy.

Case 2: A 22-year-old woman with perinatally acquired HIV, virally suppressed on ART, presented after 8 days of illness with nodulopustular and severe genital mpox. Disseminated TB was confirmed via urine LF-LAM. She was started on anti-tuberculosis therapy, continued her ART, improved clinically, and was discharged after 10 days.

Case 3: A 28-year-old woman with HIV who had stopped ART for over a year presented with two weeks of widespread nodulopustular lesions. Initially misdiagnosed as disseminated herpes, she was restarted on ART. She became unconscious and died shortly after starting ART, raising concerns for unmasking IRIS.

Conclusion:

Mpox in PLHIV with severe immunosuppression is associated with high morbidity and mortality, especially when combined with disseminated TB and delayed ART initiation or reinitiation. Early recognition, integrated HIV/TB/mpox assessment, and careful timing of ART are crucial in high-burden settings to improve clinical outcomes.