The index case that led to the recognition of the outbreak is described, and what is currently known about the outbreak is detailed in a preliminary report.

A new report provides details on the index case in the recent outbreak of fungal meningitis associated with contaminated methylprednisolone injections.

An immunocompetent man in his 50s presented with headache and neck pain; 4 weeks earlier, he had received a lumbar epidural injection of methylprednisolone. Although computed tomography of the head was unrevealing, cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis and marked hypoglycorrhachia. One of several CSF samples grew Aspergillus fumigatus. Despite antifungal therapy, the patient developed seizures, and his mental status declined. Further neuroimaging revealed evidence of a mycotic aneurysm and cerebral and cerebellar infarcts. The patient died on hospital day 22, after discontinuation of life support. Autopsy revealed branching hyphae consistent with Aspergillus in the lumbar epidural region as well as within the wall of a cerebellar artery aneurysm. CSF analysis revealed high levels of Aspergillus antigen, but Aspergillus did not grow in cultures of samples collected postmortem.

Comment: This case led to the identification of a multistate outbreak of fungal meningitis associated with epidural injections of methylprednisolone. As Kauffman and colleagues point out, what is interesting is that another fungus, Exserohilum rostratum, appears to be the culprit in most of the 200-plus other cases so far identified. As of October 22, 2012, this mold had been cultured or identified by polymerase chain reaction in the CSF of 52 patients and has been detected in unopened vials from implicated lots of methylprednisolone.

More than 14,000 persons may have been exposed to contaminated drug injections. Persistent headache, CSF neutrophil predominance, and posterior circulation stroke are common presentations. The incubation period has usually been 1 to 4 weeks, but the maximum is unknown. Currently, voriconazole alone — or, in patients with severe or refractory central nervous system disease, combined with intravenous liposomal amphotericin B — for at least 3 months is recommended.

Source: Journal Watch Infectious Diseases