Contaminated steroids used in epidural steroid injections for neck pain linked to fourteen fungal meningitis deaths so far.

The number of patients now thought exposed to the potentially contaminated methylprednisolone acetate causing an outbreak of deadly fungal meningitis has risen to some 14,000 according to the CDC. Around 12,000 individuals have so far been contacted to explain the risk after they received the potentially contaminated epidural steroid injections for neck pain or a steroid injection into a joint such as the knee, shoulder or ankle. Epidural steroid injections for cervical spinal stenosis are sometimes used to relieve inflammation in pain, although lumbar spinal stenosis injections are more common for back pain as such injections can be problematic at the best of times in the complex area of the cervical spine.

## Fourteen Deaths after Epidural Steroid Injections with Contaminated Drugs

Fourteen deaths have occurred so far, with 170 cases of infection reported across eleven states. Michigan, Tennessee and Virginia have seen the highest number of reported cases and all the cases but one have been fungal meningitis, with the exception being infection of the joint rather than the meninges (though fungal infection is yet to be confirmed). The CDC expects to hear of more cases of joint infection in patients having received the potentially contaminated medication that originated from the New England Compounding Center in Framingham, Massachusetts.

## Symptoms of Infection to Watch for

In charge of the case for the CDC is J. Todd Weber, MD, who notes that patients may present with fever, increased pain, redness, warmth or swelling in the joint where they received their injection. The first patient diagnosed with fungal meningitis was from Tennessee and had documented evidence of Aspergillus infection, his case was reported to the CDC on September 21st, with the next case reported outside of Tennessee on the 28th of September. The fungus Exserohilum has been confirmed in ten people with meningitis since that time and another three cases of infection with this fungal agent have been confirmed by non-CDC laboratories.

## Fungal Meningitis Rare, Epidural Steroid Injections for Pain Relief Common

Cases of fungal meningitis are rare and patients routinely have epidural steroid injections for pain relief from spinal stenosis or other spine conditions. Such injections are also used diagnostically as selective nerve root blocks to determine which, if any, of the spinal nerves are responsible for a patient’s pain prior to scheduling back surgery. Epidural steroid injections can reduce inflammation, relieve pain and allow patients to undergo more extensive physical therapy to increase range of motion and repair the joint.

Patients and physicians warned to watch for meningitis symptoms for several months after the steroid injections.

## Negative Test Results do Not Rule Out Infection

This is the first time that Exserohilum has been revealed as the cause of fungal meningitis and, as such, this deadly outbreak is new territory for the CDC and its partners. The fungus can be difficult to detect in patients’ samples, according to Dr Weber, and he stressed that physicians should not presume that a negative result on a test for the organism rules out infection. As such, patients who received one of the three contaminated lots of steroid injections, who are diagnosed with meningitis, but whose tests for fungal meningitis return as negative are still to be treated for fungal meningitis according to the guidelines issued by the CDC.

## Treating Fungal Meningitis

Two antifungal drugs are being recommended for patients with confirmed fungal meningitis from contaminated epidural steroid injections: voriconazole and liposomal amphotericin B, the former at a dose of 6mg/kg every twelve hours (initially intravenously) and at this dose for the duration of treatment, and the latter at a dose of 7.5mg/kg intravenously daily. These drugs can be difficult for patients to tolerate over longer periods of time and so physicians should monitor the CDC’s guidelines to stay updated on the best course of action for their patients. Prophylactic treatment in asymptomatic patients exposed to the steroids is not recommended but monitoring should continue in order to apply treatment early should it be needed.

## Symptoms of Meningitis and Neck Pain

Patients receiving the potentially contaminated epidural steroid injections for neck pain or back pain, or joint injections for pain relief may develop symptoms one to four weeks after treatment and so more cases are thought likely to arise in the coming weeks. Some patients may develop symptoms several weeks after injections, however, meaning that physicians are being advised to stay vigilant for several months after the injection. There is also the difficulty of many patients with neck pain and stiffness caused by meningitis simply putting symptoms down to chronic neck pain for which they initially had the steroid injections.

Symptoms of the fungal meningitis outbreak include reports of headaches in almost all patients, with half of the patients reporting fever, back pain or nausea. Symptoms ranged from mild to severe and other signs of fungal meningitis include neurological deficits that may resemble deep brain stroke.

## Fungal Meningitis Outbreak Spreads, Death Toll Rises

The infection and death count so far is as follows:

• Florida (7 cases, 2 deaths)
• Idaho (1 case)
• Indiana (21 cases, 1 death)
• Maryland (13 cases, 1 death)
• Michigan (39 cases, 3 deaths)
• Minnesota (3 cases)
• New Jersey (2 cases)
• North Carolina (2 cases)
• Ohio (3 cases)
• Tennessee (49 cases, 6 deaths)
• Virginia (30 cases, 1 death).

## NECC Lab Shut Down for Investigation

The laboratory from which the contaminated steroids originated is now under investigation by the FDA, with Madeleine Biondolillo, MD, director of the Massachusetts Department of Public Health’s Division of Health Care Quality in Boston, saying in a recent briefing that the NECC appears to have violated certain licensing regulations, despite their assertion otherwise. All healthcare providers have been warned to stop using any products from the NECC for fear of contamination and to check patient records in order to catch any further cases of fungal meningitis early, thereby increasing the chances of survival and successful treatment. The NECC voluntarily recalled the suspected contaminated products but the CDC went further in advising against using any products originating from the laboratory, until the investigation is complete.

Some 75 facilities in 23 states are thought to have received shipments of the steroids thought to be contaminated and patients scheduled for epidural steroid injections for neck pain relief may find that their procedures are delayed while alternative drugs are obtained.

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