Note: This story was written Oct. 19 and updated Oct. 31.
In a published clinical observation, researchers have provided details about the clinical care, deterioration and death of one of the index cases in the ongoing fungal meningitis outbreak.
The authors treated a 51-year-old patient who initially sought emergency medical care for occipital headaches radiating to the face one week after having an epidural steroid injection in her neck. The otherwise healthy patient returned to the ED the next day with troublesome neurological symptoms. Over the next several days, her health continued to deteriorate rapidly, until she died 10 days later. An autopsy revealed severe brain and spinal cord damage.
The researchers concluded that the patient was contaminated with Exserohilum species, a species of fungus with a short, unknown incubation time. Clinicians and the public should be aware of the signs and symptoms of fungal meningitis following joint or bone injections, because in this outbreak, rapid diagnosis and treatment may be necessary to prevent serious complications and death, the authors reported Oct. 17 on the website of the Annals of Internal Medicine (http://annals.org/article.aspx?articleid=1384432).
A big toll
Almost 14,000 patients may be at risk for fungal meningitis after exposure to tainted steroid injections of preservative-free methylprednisolone acetate that were manufactured by the New England Compounding Center of Framingham, Mass., according to the Centers for Disease Control and Prevention (www.cdc.gov/HAI/outbreaks/clinicians/index.html).
The injections are believed to be responsible for 368 cases of fungal meningitis and nine cases of joint infection — with 28 deaths — in 19 states as of Oct. 31. The hardest-hit states have been Michigan (107 cases, seven deaths), Tennessee (74 cases, 11 deaths), Indiana (48 cases, three deaths), Virginia (45 cases, two deaths), Florida (23 cases, three deaths) and Maryland (22 cases, one death).
Cases also have been reported in New Jersey (18), New Hampshire (14), Ohio (14), Minnesota (10), North Carolina (three cases, one death), Georgia, Idaho, Illinois, New York, Pennsylvania, Rhode Island, South Carolina and Texas (one case each). The tainted product also was shipped to California, Connecticut, Nevada and West Virginia.
The exposed patients received the medication either into the spinal area or a joint space such as a knee, shoulder or ankle. The Food and Drug Administration has stated that other products from the same manufacturer may be similarly tainted. The FDA advises following up with patients who received an injectable product, including an ophthalmic drug that is injectable or used in conjunction with eye surgery; or a cardioplegic solution purchased from or produced by NECC after May 21, 2012. (The FDA has prepared a sample patient notification letter: www.fda.gov/downloads/Drugs/DrugSafety/UCM324538.pdf?source=govdelivery.)
What to watch for
Among people with meningitis in this outbreak for whom clinical information is available, the onset of symptoms typically has been between one and four weeks following injection. "However, we want to emphasize that we know fungal infections can be slow to develop, and that there are indeed reports of longer periods of time between the injection and the onset of symptoms, so patients and their doctors will need to be vigilant for at least several months following the injection," said J. Todd Weber, MD, incident manager of the multistate meningitis outbreak at the CDC.
Patients with meningitis have presented with a variety of symptoms including fever, new or worsening headache, nausea or a new neurological deficit consistent with a deep brain stroke, Weber said. Almost all patients have reported headaches and half have reported fever, back pain or nausea. Some of these patients’ symptoms were mild. "Given the severity of the fungal meningitis, time is of the essence," Weber said. "We know we can save lives by identifying patients early and getting them on appropriate anti-fungal therapy."
Patients with joint infection may present with symptoms including fever and increased pain, redness, warmth or swelling in the joint where they received the injection or at the injection site.
Because the fungus in question can be difficult to detect in lab tests, Weber said, "patients and their clinicians should not assume fungal testing that is negative means there is no infection. In other words, patients who received an injection with one of the three recalled lots of steroids may be diagnosed with meningitis, but their fungal testing may be negative. In these cases, patients should still be treated for fungal meningitis."
In a published clinical observation, researchers have provided details about the clinical care, deterioration and death of one of the index cases in the ongoing fungal meningitis outbreak.
The authors treated a 51-year-old patient who initially sought emergency medical care for occipital headaches radiating to the face one week after having an epidural steroid injection in her neck. The otherwise healthy patient returned to the ED the next day with troublesome neurological symptoms. Over the next several days, her health continued to deteriorate rapidly, until she died 10 days later. An autopsy revealed severe brain and spinal cord damage.
The researchers concluded that the patient was contaminated with Exserohilum species, a species of fungus with a short, unknown incubation time. Clinicians and the public should be aware of the signs and symptoms of fungal meningitis following joint or bone injections, because in this outbreak, rapid diagnosis and treatment may be necessary to prevent serious complications and death, the authors reported Oct. 17 on the website of the Annals of Internal Medicine (http://annals.org/article.aspx?articleid=1384432).
A big toll
Almost 14,000 patients may be at risk for fungal meningitis after exposure to tainted steroid injections of preservative-free methylprednisolone acetate that were manufactured by the New England Compounding Center of Framingham, Mass., according to the Centers for Disease Control and Prevention (www.cdc.gov/HAI/outbreaks/clinicians/index.html).
The injections are believed to be responsible for 368 cases of fungal meningitis and nine cases of joint infection — with 28 deaths — in 19 states as of Oct. 31. The hardest-hit states have been Michigan (107 cases, seven deaths), Tennessee (74 cases, 11 deaths), Indiana (48 cases, three deaths), Virginia (45 cases, two deaths), Florida (23 cases, three deaths) and Maryland (22 cases, one death).
Cases also have been reported in New Jersey (18), New Hampshire (14), Ohio (14), Minnesota (10), North Carolina (three cases, one death), Georgia, Idaho, Illinois, New York, Pennsylvania, Rhode Island, South Carolina and Texas (one case each). The tainted product also was shipped to California, Connecticut, Nevada and West Virginia.
The exposed patients received the medication either into the spinal area or a joint space such as a knee, shoulder or ankle. The Food and Drug Administration has stated that other products from the same manufacturer may be similarly tainted. The FDA advises following up with patients who received an injectable product, including an ophthalmic drug that is injectable or used in conjunction with eye surgery; or a cardioplegic solution purchased from or produced by NECC after May 21, 2012. (The FDA has prepared a sample patient notification letter: www.fda.gov/downloads/Drugs/DrugSafety/UCM324538.pdf?source=govdelivery.)
What to watch for
Among people with meningitis in this outbreak for whom clinical information is available, the onset of symptoms typically has been between one and four weeks following injection. "However, we want to emphasize that we know fungal infections can be slow to develop, and that there are indeed reports of longer periods of time between the injection and the onset of symptoms, so patients and their doctors will need to be vigilant for at least several months following the injection," said J. Todd Weber, MD, incident manager of the multistate meningitis outbreak at the CDC.
Patients with meningitis have presented with a variety of symptoms including fever, new or worsening headache, nausea or a new neurological deficit consistent with a deep brain stroke, Weber said. Almost all patients have reported headaches and half have reported fever, back pain or nausea. Some of these patients’ symptoms were mild. "Given the severity of the fungal meningitis, time is of the essence," Weber said. "We know we can save lives by identifying patients early and getting them on appropriate anti-fungal therapy."
Patients with joint infection may present with symptoms including fever and increased pain, redness, warmth or swelling in the joint where they received the injection or at the injection site.
Because the fungus in question can be difficult to detect in lab tests, Weber said, "patients and their clinicians should not assume fungal testing that is negative means there is no infection. In other words, patients who received an injection with one of the three recalled lots of steroids may be diagnosed with meningitis, but their fungal testing may be negative. In these cases, patients should still be treated for fungal meningitis."
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