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Preliminary results of ongoing multistate meningitis outbreak released
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A rapid public health response was crucial in managing the 2012 multistate fungal meningitis outbreak, researchers concluded after investigating fungal infection cases in Tennessee where the outbreak was discovered.
“The investigation of this outbreak in Tennessee required a close and collaborative approach between the public health system and the medical community,” the researchers wrote in The New England Journal of Medicine. “Maintaining a strong public health infrastructure is critical to ensuring that there is capacity to investigate such outbreaks quickly and effectively.”
Marion A. Kainer
Members of Tennessee’s fungal meningitis investigation team performed a cohort analysis of all patients across three clinics who received injections of tainted preservative-free methylprednisolone acetate and later developed fungal meningitis, posterior circulation stroke, spinal osteomyelitis or epidural abscess. Data were obtained through medical chart reviews and interviews with patients, their families and physicians.
A total of 1,009 patients received injections from one or more of three recalled lots of methylprednisolone. Sixty-six patients (7%) developed complications associated with the tainted lots through Oct. 19.
Results further indicated that the median time from the last injection to symptom onset was 18 days. Of the 66 patients, 73% presented with meningitis only, 15% with cauda equina syndrome or focal infection and 12% with posterior circulation stroke with or without meningitis. Symptoms included headache (73%), back pain (50%), neurologic symptoms (48%), nausea (39%) and stiff neck (29%). Exserohilum rostratum infection was confirmed in 21 patients and Aspergillus fumigatus infection was confirmed in one patient.
Eight patients died (12%), seven of whom had stroke.
In a cohort analysis of one clinic, the risk for fungal infection increased with exposure to methylprednisolone from lot 06292012@26 vs. either one of the other tainted lots (RR=4; 95% CI, 1.8-8.6). The risk for infection also increased for patients treated with older vials (RR=6.2; 95% CI, 2.6-14.5), multiple procedures (RR=2.9; 95% CI, 1.7-5) and epidural glucocorticoid injections using the translaminar approach (RR=2.5; 95% CI, 1.3-4.8).
Voriconazole, which was recommended by the CDC to treat fungal infections, was assigned to 61 patients (92%). Thirty-five patients (53%) were also assigned liposomal amphotericin B.
“Rapid recognition and prompt initiation of therapy are important to prevent complications,” study researcher Marion A. Kainer, MB, BS, MPH, told Infectious Disease News. “This is an evolving situation — clinicians are encouraged to check the CDC website for latest information for diagnostics and management.”
The CDC has reported that 541 people have been affected by the fungal meningitis outbreak in 19 states as of Monday. There have also been 36 deaths.
Kainer MA. N Engl J Med. 2012;367:2194-2203.
Disclosure: Study researcher Marion A. Kainer, MB, BS, MPH, a full-time employee at the Tennessee Department of Health, reports receiving several grants from the CDC and owning stock in Infectious Diseases Consulting Corp.
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