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Nov. 20, 2012-CDC Health Advisory-Fungal Meningitis Update

On Behalf of | Nov 22, 2012 | Fungal Meningitis

Update: Multistate Outbreak of Fungal Meningitis and Other Infections Associated with Contaminated Steroid Medication

Distributed via Health Alert Network November 20, 2012, 15:00 ET (3:00 PM ET)

Summary   The Centers for Disease Control and  Prevention (CDC) continues to work closely with state public health departments  on a multistate investigation of fungal meningitis and other infections among  patients who received a methylprednisolone acetate (MPA) injection prepared by  the New England Compounding Center (NECC) in Framingham, Mass. This HAN notice  provides updated information on the following:

  • Epidural abscess and other clinical syndromes being diagnosed in exposed patients
  • Diagnostic and treatment recommendations  for clinicians

Background   As of November 19, 2012, a  total of 490 cases, which includes 34 deaths, have been reported in 19 states  (see CDC’s website for up-to-date information about case count and  distribution by state). Exserohilum  rostratum continues to be the predominant fungus identified in patients and  confirmed by the CDC laboratory.

Clinical Syndromes Reported to CDC Currently, more than 7 weeks after the three implicated lots of  MPA1 were recalled, CDC continues to receive reports of fungal  infection in exposed patients. Previously, the majority of new cases reported  to CDC were patients with fungal meningitis following injection.

Although cases of fungal meningitis continue to be reported, CDC  has recently observed an increase in the number of patients presenting with  evidence of epidural abscess, phlegmon, discitis, vertebral osteomyelitis, or arachnoiditis  at or near the site of injection. These complications have occurred in patients  with and without evidence of fungal meningitis.

Of the 91 cases reported to CDC since November  4, 2012, a total of 26 (29%) were classified as meningitis, 61 (67%) had spinal  or paraspinal epidural abscess or osteomyelitis, 2 (2%) had peripheral joint  infection and 2 (2%) had more than one condition (Figure 1).

Note: Data presented in Figure 1 are preliminary and subject to change. Additional patients may ultimately meet multiple case definitions (e.g., meningitis and osteomyelitis/abscess) as more time elapses and additional information is provided to CDC. Reporting dates to CDC may lag behind onset dates.

Diagnostic and Treatment Guidance   As a reminder, CDC’s  current diagnostic and treatment guidance addresses management of patients with epidural abscess or other complications  at or near the injection site. These localized infections may occur in  isolation or in patients previously diagnosed with fungal meningitis. Although  patients with these localized infections frequently have new or worsening back  pain, symptoms may be mild or clinically difficult to distinguish from the  patient’s baseline chronic pain. Based on current information, CDC recommends  the following diagnostic protocol:

  • In patients with new or worsening symptoms at or near the  injection site, physicians should obtain an MRI with contrast of the  symptomatic area(s), if not contraindicated. This recommendation also applies to patients being treated for meningitis. In some cases, radiologic  evidence of abscess or phlegmon has become apparent on repeat MRI studies  performed subsequent to an initially normal imaging procedure. Clinicians  should therefore have a low threshold for repeat MRI studies  in patients who continue to have symptoms localizing to the site of injection,  even after a normal study. However, the optimal duration between MRI  studies is unknown.
  • CDC has received reports of patients being treated for fungal  meningitis who had no previous evidence of localized infection at the site of  injection, but who were subsequently found to have evidence of localized  infection (e.g., epidural abscess, phlegmon, discitis, vertebral osteomyelitis,  or arachnoiditis) on imaging studies. Therefore, in patients being treated for  meningitis, even in the absence of new or worsening symptoms at or near the  injection site, clinicians should strongly consider obtaining an MRI of the  injection site approximately 2-3 weeks after diagnosis of meningitis. Early  identification of new disease may facilitate additional specific interventions  (e.g., drainage) and provide information for measuring effectiveness of therapy  thereafter.
  • For patients demonstrated to have epidural abscess, phlegmon, discitis, vertebral osteomyelitis, or arachnoiditis, early  consultation with a neurosurgeon to discuss  whether surgical management, including  debridement, is warranted in addition to antifungal therapy (for information  about antifungal therapy, see Interim Treatment Guidance for Central Nervous  System and Parameningeal Infections Associated with Injection of Contaminated  Steroid Products

CDC continues to gather data from existing and newly reported  cases of infection and will use this information to inform updates to existing  guidance. Healthcare professionals with patients under their care should check CDC’s website for the  most up-to-date clinical guidance because information is subject to change.

1NECC lots of methylprednisolone acetate (PF) 80mg/ml:

Methylprednisolone Acetate (PF) 80 mg/ml  Injection, Lot #[email protected], BUD 11/17/2012   Methylprednisolone Acetate (PF) 80 mg/ml  Injection, Lot #[email protected], BUD 12/26/2012   Methylprednisolone Acetate (PF) 80 mg/ml  Injection, Lot #[email protected], BUD 2/6/2013

The Centers for  Disease Control and Prevention (CDC) protects people’s health and safety by  preventing and controlling diseases and injuries; enhances health decisions by  providing credible information on critical health issues; and promotes healthy  living through strong partnerships with local, national, and international  organizations.


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