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Meningitis outbreak affects 170 people, kills 14
The CDC has estimated that nearly 14,000 people have been exposed to the three affected lots of methylprednisolone acetate that have been linked to a fungal meningitis outbreak that, so far, has affected 170 people and caused 14 deaths in 11 states.
In addition, they have also stated that the affected steroid injections may also cause joint infections when injected into a joint, J. Todd Weber, MD, incident manager of the multistate meningitis outbreak and chief of the Prevention and Response Branch of the CDC, said during a media briefing on Thursday.
Weber also said Exherohilum has been identified as the primary fungus involved in the 13 patients who developed meningitis from an epidural steroid injection. Aspergillus was identified in one patient.
“Exherohilum can be difficult to detect in samples from patients,” Weber said. “Patients and their clinicians should not assume that negative fungal tests mean there is no infection. If a patient received an injection from one of the three affected lots, the patient should still be treated for fungal meningitis. Similarly, curing these infections requires prolonged treatment. Patients should adhere to the treatment recommendations of their physicians.”
Following advice from a panel of fungal infection experts, CDC recommends that patients with confirmed fungal meningitis receive two antifungal drugs: voriconazole and liposomal amphotericin B. CDC is working with experts to determine the best dose and the best length of time to receive treatment. Weber said as more information is discovered by CDC and FDA laboratories, clinical recommendations may change.
“Historically, fungal meningitis is very rare, and Exherohilum has not been seen previously as a cause of fungal meningitis,” Weber said. “This is new territory for public health and the clinical community.”
He said fungal infections can be slow to develop. There are reports of longer periods of time between injection and onset of symptoms. Thus far, those with confirmed meningitis have reported symptom onset occurring 1 to 4 weeks after injection. Patients and their doctors must be vigilant for several months after injection, Weber added.
CDC confirmed one instance of joint infection after injection of the implicated medication. Weber said laboratory results for this patient are not confirmed, but he expects to see additional patients come forward that report fever, increased pain, redness and swelling in the joint where they received the injection.
Of the 14,000 patients who have potentially been expose, the CDC and state and local health departments have contacted more than 12,000 to inform them of the risk, Weber said.
“We know we are not out of the woods yet,” he said. “We are making sure that patients understand that if they develop symptoms of meningitis or joint infection in the coming weeks, they need to seek medical care immediately.”
Symptoms include headaches, fever, back pain and nausea. Weber said some of the patient symptoms are mild.
“Given the severity of fungal meningitis, time is of the essence,” he said. “We know we can save lives by identifying patients early and getting them on appropriate antifungal therapy.”
Perspective
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This outbreak of fungal meningitis is going to be of interest to all infectious disease physicians. Aspergillus meningitis is extraordinarily rare and there will be continuing challenges in diagnosing and treating these infections. It is expected that more cases will be discovered over the next several weeks as more patients and their health care providers become acquainted with this issue and initiate diagnostic testing.
It may well be that we will also see infections with other fungi, as well as infections at other anatomic sites because some of these medications were used to treat patients with joint diseases.
The outbreak illustrates that the regulatory oversight of the FDA does not extend to compounding pharmacies. This has created a gap in the assurance that the medications being used to treat patients in United States in the 21st century are always safe. It is hoped that this gap can be closed to prevent similar events in the future.