Fatalities reported from rare fungal meningitis

Robin Wulffson MD's picture
fungal meningitis, fatalities, back pain, steroid injections, methylprednisolone
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A rare but deadly type of meningitis has killed four individuals and sickened more than two dozen in five states. In addition, health officials expect to find more cases. All the infected individuals received a steroid injection for back pain, which is a common form of treatment.

The majority of the patients (18) were reported in Tennessee, where a Nashville clinic received the largest shipment of the steroid. The drug was manufactured by a specialty pharmacy in Massachusetts. The manufacturer issued a recall of the medication last week; however, investigators are trying to confirm the source of the injection. One of the newly-infected patients in Tennessee received an injection of the steroid methylprednisolone acetate at the Specialty Surgery Center in Crossville, Tennessee. Another received an injection from a second lot of the steroid, which is the substance most likely to be responsible for the infection.

According to the Centers for Disease Control and Prevention, three cases have been reported in Virginia, two occurred in Maryland, two in Florida, and one occurred in North Carolina. Two of the deaths were in Tennessee; one death occurred in Virginia and one death occurred in Maryland. Unlike more common forms of meningitis, the type of meningitis involved in the infections is not contagious like the more common forms. This type is caused by a fungus often found in leaf mold. Health officials suspect that the fungus may have contaminated the steroid.

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In an October 3 press conference, Tennessee Department of Health Commissioner John Dreyzehner noted that more new cases are almost certain to appear in the coming days. He described the situation as a “rapidly evolving outbreak.” He noted that five new cases were confirmed over the past 24 hours. He explained that biopsy specimens from two patients contained the fungus Aspergillus. He stressed that the outbreak has no relationship to other cases of bacterial or viral meningitis recently occurring in Tennessee. He added that women who receive epidurals during delivery have no reason to be concerned about this cluster of cases.
He provided details regarding the first 12 meningitis cases that occurred in Tennessee. The patients ranged in age from 49 to 89 years. Nine of the first 12 were female. He noted that some details could not be made public at this time due to privacy concerns; however, he assured that new data of public interest would be disseminated when it became available. CDC officials have noted that it is unclear whether new infections are occurring. They are looking for, and increasingly finding, illnesses that occurred in the past two or three months.

In regard to the currently infected patients in Tennessee, state health official Dr. David Reagan noted, “Some are doing well and improving. Some are very ill; very, very seriously ill and may die.” The incubation period ranges from between two to 28 days; therefore, some people may not have fallen ill yet. At three clinics in Tennessee, officials are contacting the more than 900 people who received the steroid in the past three months. Investigators also have been looking into the antiseptic and anesthetic used during the injections. Neither has been ruled out. However, the primary suspicion is on the steroid medication. Steroid injections, which are commonly administered for back pain, are often given together with an anesthetic.

The Food and Drug Administration (FDA) identified the maker of the steroid as New England Compounding Center, a specialty pharmacy in Framingham, Mass. Last week, the company issued a recall of three lots of methylprednisolone acetate. In a statement, the company said it had voluntarily suspended operations and was working with regulators to identify the source of the infection. Compounding pharmacies mix ingredients for customized medicines that generally are not commercially available. They are regulated by states.

Meningitis is caused by the inflammation of meninges, which are protective membranes covering the brain and spinal cord. Symptoms of the infection include severe and worsening headache, nausea, dizziness, and fever. Tennessee health officials noted that some of the patients also experienced slurred speech, difficulty walking, and difficulty in urinating, The CDC notes that fungal meningitis is rare, but can be life threatening. Although anyone can get fungal meningitis, individuals at higher risk include those who have AIDS, leukemia, or other forms of immunodeficiency. Patients receiving immunosuppressive therapy are also at increased risk.

References:
CDC
Tennessee Department of Health

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