Fungal Meningitis Cases Linked to Injected Steroid

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October 18, 2012

The Centers for Disease Control and Prevention (CDC) continue to report additional cases and deaths from an outbreak of fungal meningitis linked to contaminated steroid injections given to relieve back pain. The CDC is regularly updating case counts and progress on the investigation on its web site. As of October 17, 2012, there have been 19 deaths in fifteen states. Currently, 245 patients who received spinal injections have been diagnosed with very serious infections, according to the CDC and the Food and Drug Administration (FDA). Some patients who received the injection have also suffered strokes related to the meningitis.

The steroid injection, preservative-free methylprednisolone acetate, was distributed by compounding pharmacy firm New England Compounding Center (NECC), which has recalled all products made at its plant in Framingham, Massachusetts. The contamination might affect other compounded drugs as well, and there is preliminary evidence suggesting this may have occurred with at least two other products. The FDA is advising physicians not to use any products made by the company, which has now shut down.

Over 13,000 people may have received the injections, but only about 5% are likely to contract the meningitis, according to recent reporting by Reuters. Compounding pharmacies use raw ingredients to make pharmaceutical products typically not produced on a mass scale and while the FDA regulates the raw ingredients, there is no federal oversight of the compounding practices. The FDA has found contamination in sealed vials of the steroid and is investigating other medications from the pharmacy. The CDC has identified two different fungi, Aspergillus fumigatus and Exserohilum rostratum, present in the spinal fluid of patients who received the injectable steroid.

Fungal meningitis, unlike bacterial meningitis, is not contagious, according to the CDC. In the current outbreak, it is likely that the fungus was introduced at the injection site and then spread into the central nervous system.

The symptoms of fungal meningitis are similar to symptoms of other forms of meningitis—headache, fever, nausea, stiffness of the neck-- though in cases of fungal meningitis, symptoms can be mild to start with and progress gradually. People with fungal meningitis may also have confusion, sensitivity to bright lights and dizziness, and may have only some of these symptoms. Patients who contracted the fungal meningitis developed symptoms one to four weeks after the injection.

The CDC is advising doctors to test patients who have even very mild central nervous system symptoms if they received the steroid injection with a drug from the recalled lots. This involves collecting a sample of cerebrospinal fluid (CSF) with a spinal tap and performing the appropriate bacterial and fungal tests.

Two cases of joint infections related to the contaminated steroid have also been reported. Patients who received injections in other sites, such as joints, should be examined for signs of infection, such as swelling, increasing pain, redness, and warmth at the injection site. If the symptoms persist, fungal testing of joint fluid should be done. The CDC also advises doctors to let state health departments know about patients who are being evaluated for fungal meningitis or septic arthritis linked to the injections, in order to keep accurate case counts.

Treatment requires intravenous antifungal drugs for weeks to months; these drugs can cause serious side effects, including kidney damage.

The CDC is maintaining a web page with the latest information on the outbreak for the public: Frequently Asked Questions for Patients

A map of health care facilities that received the recalled lots of medication is also available.

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NOTE: This article is based on research that utilizes the sources cited here as well as the collective experience of the Lab Tests Online Editorial Review Board. This article is periodically reviewed by the Editorial Board and may be updated as a result of the review. Any new sources cited will be added to the list and distinguished from the original sources used.

(October 5, 2012) Tim Ghianni. Number of U.S. meningitis cases rises to 50 in deadly outbreak. Reuters. Available online at http://www.reuters.com/article/2012/10/05/us-meningitis-idUSBRE89412420121005 through http://www.reuters.com. Accessed October 10, 2012.

(October 10, 2012) Steven Reinberg and Margaret Steele. Meningitis Toll Now 12 Dead, 137 Sick: CDC. Healthday. Available online at http://consumer.healthday.com/Article.asp?AID=669499 through http://consumer.healthday.com. Accessed October 10, 2012.

(October 12, 2012) Food and Drug Administration. Statement on Fungal Meningitis Outbreak. Available on line at http://www.fda.gov/Drugs/DrugSafety/ucm322734.htm through http://www.fda.gov. Accessed October 12, 2012.

(October 12, 2012) Food and Drug Administration. Questions and Answers on Fungal Meningitis Outbreak. Available online at http://www.fda.gov/Drugs/DrugSafety/ucm322735.htm through http://www.fda.gov. Accessed October 12, 2012.

(October 4, 2012) Centers for Disease Control and Prevention. Health Advisory, Meningitis and Stroke Associated with Potentially Contaminated Product. Availble online at http://emergency.cdc.gov/HAN/han00327.asp through http://emergency.cdc.gov. Accessed October 12, 2012.

(October 7, 2012) Centers for Disease Control and Prevention. Frequently Asked Questions For Clinicians: Multistate Meningitis Outbreak Investigation. Available online at http://www.cdc.gov/hai/outbreaks/clinicians/faq_meningitis_outbreak.html through http://www.cdc.gov. Accessed October 12, 2012.

(October 11, 2012) Centers for Disease Control and Prevention. Healthcare-associated Outbreaks, Multistate Meningitis Outbreak Investigation. Available online at http://www.cdc.gov/hai/outbreaks/meningitis.html through http://www.cdc.gov. Accessed October 12, 2012.

(October 5, 2012) Centers for Disease Control and Prevention. Fungal Meningitis. Available online at http://www.cdc.gov/meningitis/fungal.html through http://www.cdc.gov. Accessed October 12, 2012.