Multistate Outbreak of Fungal Meningitis and Other InfectionsIn mid-Septemberthe largest healthcare-associated outbreak in U. Before it was over, patients were reported with fungal meningitis, stroke, spinal or paraspinal infection, or peripheral osteoarticular infection, and 64 8. Most patients had undergone epidural injection, and a few osteoarticular injection, of methylprednisolone acetate that had been manufactured at the New England Compounding Center NECC. The offending pathogen in most cases was Exserohilum rostratum, a brown-black soil organism that previously was a rare cause of human infection. Three lots of methylprednisolone were contaminated with mold at NECC; the mold from unopened bottles of methylprednisolone was identical by whole-genome sequencing to the mold that was isolated from ill patients. Early cortisone injection for bursitis in toe manifested as meningitis, some patients suffered posterior circulation strokes, and later cases were more likely to present with localized infection fungal infection after steroid injection the injection site, including epidural abscess or phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with intradural involvement of nerve roots. Many patients with spinal or fungal infection after steroid injection infection required surgical intervention.
Multistate Outbreak of Fungal Meningitis and Other Infections | HAI | CDC
Findings suggest black mold targeting the base of the brain, reports The American Journal of Pathology. Investigators from the Centers for Disease Control and Prevention CDC describe pathologic findings from 40 case reports of fungal infection in patients who had been given contaminated epidural, paraspinal, or intra-articular into joints steroid injections and correlate these findings with clinical and laboratory data.
The report, published in the September issue of The American Journal of Pathology , alerts clinicians and the general public to the catastrophic dangers of contaminated epidural injections. In September , CDC began hearing multiple reports of fungal meningitis in patients following epidural steroid injections. By June , people had confirmed infections and 58 had died, making this the largest reported outbreak of infections associated with epidural and intra-articular injections.
After intensive investigation, the contamination was traced to more than 17, vials from three contaminated lots of preservative-free methylprednisolone acetate MPA originating from a single compounding pharmacy.
More than 13, people were injected with the potentially contaminated drug. Most cases were attributable to Exserohilum rostratum, a dark-colored environmental mold that rarely infects humans. Researchers, including the CDC's Exserohilum Infections Working Group, report that of 40 cases reviewed, 16 were fatal, and all except two fatal cases had a clinical diagnosis of meningitis.
Autopsy examination showed extensive hemorrhage and necrosis tissue decay around the base of the brain and thrombi clots involving the basilar arterial circulation. Tissue specimens from infected individuals showed inflammation of the leptomeninges thin membranes lining the brain and blood vessel walls within the brain. Distinctive abnormalities were observed around blood vessels, and fungus was found around and within arterial walls. Interestingly, fungus deep within the brain tissue itself was found in only one case.
Similar pathologic findings were seen at the epidural injection site. Fungus was not found in tissue samples taken from the heart, lung, liver, or kidney. Investigators wondered why fungus injected in the spinal region should target the base of the brain.
This supports the hypothesis that Exserohilum migrates from the lumbar spine to the brain through the cerebrospinal fluid with subsequent vascular invasion, rather than migration through the vasculature," suggests Jana M. In addition to characterizing the histopathology seen in this outbreak, the authors also provide practical information for pathologists, including an evaluation of various diagnostic methods to detect the fungal infection in tissues.
Factors that may affect cellular inflammatory patterns and fungal concentration are discussed, and the authors note that their findings may reflect the simultaneous introduction of the fungus along with the steroid. Notes for Editors " Exserohilum infections associated with contaminated steroid injections: A clinicopathologic review of 40 cases," by Jana M. Ritter, Atis Muehlenbachs, Dianna M. Montague, Elizabeth White, Dominique C.
The editors accept manuscripts that advance basic and translational knowledge of the pathogenesis, classification, diagnosis, and mechanisms of disease, without preference for a specific analytic method. High priority is given to studies on human disease and relevant experimental models using cellular, molecular, animal, biological, chemical, and immunological approaches in conjunction with morphology.
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