Fungal meningitis stats continue to worsen
Each day, the statistics regarding fungal meningitis cases from tainted steroid injections become more alarming. On October 11, the Centers for Disease Control and Prevention (CDC) reported that the number of individuals exposed to potentially contaminated methylprednisolone acetate injections was not 13,000; the new estimate is closer to 14,000. In addition, one case has arisen in a patient who received a joint injection, rather than an epidural injection adjacent to the spinal column.
The new total is 170 cases, including 14 deaths. Infections have been reported in 11 states: Florida (7 cases, 2 deaths), Idaho (1 case), Indiana (21 cases, 1 death), Maryland (13 cases, 1 death), Michigan (39 cases, 3 deaths), Minnesota (3 cases), New Jersey (2 cases), North Carolina (2 cases), Ohio (3 cases), Tennessee (49 cases, 6 deaths), and Virginia (30 cases, 1 death). All individuals received a methylprednisolone acetate injection made by the New England Compounding Center (NECC) in Framingham, Massachusetts.
“These 14,000 patients received the medication as a steroid injection either into the spinal area or into a joint space such as a knee, shoulder or ankle,” noted J. Todd Weber, MD, incident manager of the multistate meningitis outbreak at the CDC. He added that to date, more than 12,000 of these individuals had been contacted. In addition, the CDC and the Michigan Department of Community Health have confirmed today the first patient with evidence of joint infection following injection with the tainted steroid. He explained that laboratory results are not complete at this time; therefore, a fungal origin cannot be determined. He said that, via its patient notification efforts, the CDC expects that additional patients may come forward with joint infections. The symptoms consist of fever, increased pain, redness, warmth, or swelling in the joint where the injection was given.
Dr. Weber noted that the CDC has confirmed that the fungus Aspergillus was present in laboratory samples from the first reported case in Tennessee. Subsequent cases were determined via laboratory analysis to be due to the fungus Exserohilum. The total confirmed fungus infections to date comprise one from Aspergillus and 10 from Exserohilum; furthermore, three additional Exserohilum infections have been documented by other laboratories. He explained that fungal meningitis is an extremely rare cause of meningitis and, prior to this outbreak, Exserohilum has not been reported as a cause of fungal meningitis. He noted that Exserohilum can be difficult to detect in patient samples; therefore, clinicians should not assume fungal testing that is negative means that there is no infection. He explained that individuals who received an injection with one of the three recalled lots of contaminated steroid may be diagnosed with meningitis; however, fungal testing might be negative. He recommended that in these cases, the patients given the suspect steroid should be treated for fungal meningitis.
The CDC recommends that patients with confirmed fungal meningitis should receive two antifungal drugs: voriconazole (6 mg/kg every 12 hours (intravenous initially) and to continue receiving this high dose for the duration of treatment, if possible; and liposomal amphotericin B (7.5 mg/kg intravenously daily). Dr. Weber noted that the two drugs are extremely potent and can be very difficult for patients to tolerate over a long period of time. He explained that the CDC was working with their clinical experts to determine the best dose and the best length of time to treat patients. He noted that the CDC recommendations may be modified as additional information becomes available.
In view of the side-effects of the aforementioned treatment regimen, at present, the CDC is not recommending antifungal treatment for individuals exposed to a possibly tainted injection who do not have any meningitis symptoms. However, these people should be closely monitored for development of symptoms. In addition, the CDC is not currently recommending antifungal therapy for symptomatic patients who have normal results on laboratory examination of cerebrospinal fluid. However, as in asymptomatic patients, these individuals should be closely monitored and re-evaluated for progression of symptoms.
Dr. Weber notes that the CDC expects that more cases will surface. The onset of symptoms is typically between one and four weeks; however, there are reports of longer time between injection and onset of symptoms. In view of this, Dr. Weber recommends that patients and their physicians should remain vigilant for at least several months following the injection. Symptoms of an infection include fever, new or worsening headache, nausea, and symptoms of a stroke. The CDC notes that almost all patients have reported headaches and almost half have reported fever, back pain, or nausea. In some cases, these symptoms were mild.
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