Exserohilum rostratum – Credit CDC
# 6643
The journal Annals of Internal Medicine has published a letter describing the findings of one of first index cases of fatal meningitis linked to an epidural injection with a contaminated steroid product.
Fatal Exserohilum Meningitis and Central Nervous System Vasculitis after Cervical Epidural Methylprednisolone Injection
Jennifer L. Lyons, MD; Elakkat D. Gireesh, MD; Julie B. Trivedi, MD; W. Robert Bell, MD; Deanna Cettomai, MD; Bryan R. Smith, MD; Sarah Karram, MD; Tiffany Chang, MD; Laura Tochen, MD; Sean X. Zhang, MD, PhD; Chad M. McCall, MD, PhD; David T. Pearce, BS; Karen C. Carroll, MD; Li Chen, MD, PhD; John R. Ratchford, MD, MSc; Daniel M. Harrison, MD; Lyle W. Ostrow, MD, PhD; and Robert D. Stevens, MD
Those who would like to wade through the detailed clinical findings can use the link above, but briefly: The patient was a 51 year old woman who presented at the local emergency room with a severe headache on August 31st, 2012 a week after receiving an epidural cervical injection at a pain clinic.
This was before the nationwide alert had gone out about contaminated steroids and fungal meningitis, and so the ER doctors had no reason to suspect that as a cause.
Since headaches are common after a spinal injection, the ER did a CT scan, assured themselves that she wasn’t having a stroke, and sent her home. But the next day she returned, and her symptoms now resembled meningitis (headache, double vision, dizziness, nausea), and so they admitted her.
Her condition steadily worsened over the next several days while her doctors desperately worked to solve a medical mystery.
They tested her spinal fluid for herpes simplex virus, varicella zoster virus, Epstein–Barr virus, cytomegalovirus, and West Nile virus. Antigen tests for cryptococcal and histoplasma antigens along with bacterial cultures of her cerebral-spinal fluid were negative as well.
After 8 days - despite trying acyclovir, cefepime, vancomycin, doxycycline, and (a bit ironically) methylprednisolone - her condition had grown increasingly grim, as described below:
On day 9, neurologic examination progressed to absent pupillary, corneal, and gag reflexes, and liposomal amphotericin B was added empirically.
On day 10, all brainstem reflexes were lost, and death from neurologic criteria was pronounced.
Exserohilum species was reported in the cerebrospinal fluid the same day.
Autopsy revealed a grossly necrotic brainstem, and microscopic examination showed angioinvasive, septate fungal hyphae associated with diffuse vasculitis (Figure, H) and hemorrhagic infarction in the brain and spinal cord.
In simplest terms, this fungus infected and destroyed her brainstem. The rapid progression of this infection points out how important early diagnosis and treatment will be for those infected.
Maggie Fox of NBC News has more on this story, which you can access at:
First case history shows fungal meningitis can destroy brain fast
By Maggie Fox, NBC News
She had a history of pain, the 51-year-old woman who showed up at the emergency room with a headache so bad it made her face hurt. Within 10 days she was dead, one of the first victims of an outbreak of fungal meningitis that has killed 19 people and made more than 240 sick.
According to the New York Times yesterday, doctors are debating the merits of starting prophylactic treatment in asymptomatic patients.
So far, the advice has been strongly against it, primarily because of the potential for antifungal drugs to cause liver, heart, and kidney damage.
This from the CDC’s Clinical Guidance:
Interim Guidance for Management of Asymptomatic Persons Exposed to Potentially Contaminated Steroid Products
October 14, 2012 4:30 PM EDT
Antifungal prophylaxis for patients who received epidural injections with potentially contaminated steroid products
- At this time, CDC does not recommend initiation of antifungal prophylaxis in exposed patients who are asymptomatic. These patients should be closely monitored for development of symptoms, with a low threshold for performing lumbar puncture should the patient become symptomatic. When diagnostic lumbar punctures are performed, they should be done through a site other than the site used for epidural injection when possible.
Another concern is since treatment courses could go on for months - with thousands of people exposed - the supply of anti-fungal drugs may not be sufficient to treat asymptomatic cases.
We should get an update later this afternoon on the case counts from the CDC, and perhaps some new guidance.
