Early Clinical Observations in Prospectively Followed Patients With Fungal Meningitis Related to Contaminated Epidural Steroid Injections

Kerkering TM, Grifasi ML, Baffoe-Bonnie AW, et al. — Tue, 05 Feb 2013 00:00:00 GMT

This article has been corrected. The original version (PDF) is appended to this article as a supplement.

Chinese translation

Background:

Administration of epidural steroid injections (ESIs) with contaminated methylprednisolone resulted in an outbreak of fungal meningitis in many locations in the United States.

Objective:

To characterize early clinical findings and initial response to treatment.

Design:

Case series with standardized observation studied from 4 October to 31 October 2012.

Setting:

An 800-bed hospital in Virginia.

Patients:

172 patients who presented to the hospital with exposure to contaminated ESI.

Intervention:

Standardized approach to screening, case definition, treatment, and data collection.

Measurements:

Clinical findings, cerebrospinal fluid (CSF) values, magnetic resonance imaging (MRI), serum and CSF voriconazole concentrations, and clinician assessment of response to therapy.

Results:

Of 172 patients presenting to the hospital who had had ESI, 131 had lumbar puncture because of symptoms or signs consistent with central nervous system disease. Twenty-five (19%) had neutrophilic meningitis. All were started on voriconazole therapy alone. Three patients developed stroke during treatment. Ten patients had arachnoiditis, another had an epidural abscess, and 9 had urine retention. Fifteen continued to receive voriconazole, and 10 were switched to amphotericin B. Cerebrospinal fluid leukocyte counts began to decrease by day 13 of treatment. Findings on MRI included ventriculitis, leptomeningeal enhancement, infarction, hemorrhage, and arachnoiditis. Serum voriconazole levels varied, and CSF concentrations of voriconazole were approximately 50% those of serum. Exserohilum rostratum and Cladosporium species have been cultured.

Limitations:

This is an observational study of an evolving outbreak. Not all exposed patients presented for evaluation. Follow-up is too short to determine final outcomes.

Conclusion:

Meningitis after receipt of contaminated ESI has been diagnosed in many exposed patients presenting to 1 hospital. Most patients have improved on receipt of empirical voriconazole therapy. The full natural history and long-term sequelae of this infection are currently unknown.

Primary Funding Source:

None.

Treatment of Iatrogenic Fungal Infections: A Black Mold Defines a New Gray Zone in Medicine

Shoham S, Marr KA. — Tue, 05 Feb 2013 00:00:00 GMT

As of 10 December 2012, there were 368 cases of meningitis, 192 cases of paraspinal/spinal infections, and 21 cases of arthritis clustered in 19 states, with 37 deaths, due to contaminated methylprednisolone acetate injections. This article focuses on questions likely to be on clinicians' minds: how should clinicians approach exposed persons, treat presumed or documented fungal infection, and move forward with so many unknowns.

Annals of Internal Medicine: CNS Infections Topic Collection

Early Clinical Observations in Prospectively Followed Patients With Fungal Meningitis Related to Contaminated Epidural Steroid Injections

Treatment of Iatrogenic Fungal Infections: A Black Mold Defines a New Gray Zone in Medicine