Background: Administration of epidural steroid injections (ESI) with contaminated methylprednisolone resulted in an outbreak of fungal meningitis in many locations in the United States.
Objective: Characterize early clinical findings and initial response to treatment
Design: Case series with standardized observation studied from October.4-31, 2012
Setting: 800 bed hospital in Virginia
Patients: 172 patients who presented to the hospital with exposure to contaminated ESI.
Intervention: Standardized approach to screening, case definition, treatment and data collection
Measurements: Clinical findings; cerebrospinal fluid (CSF) parameters ; magnetic resonance imaging (MRI); serum and CSF voriconazole concentrations; clinician assessment of response to therapy.
Results: Of 172 patients with ESI presenting to the hospital, 131 underwent lumbar puncture (LP) because of symptoms or signs consistent with central nervous system disease. Twenty-five, (19%) had neutrophilic meningitis. All were started on voriconazole therapy alone. Three patients developed stroke during treatment. Ten patients have arachnoiditis, another has an epidural abscess and nine experienced urinary retention. Fifteen remain on voriconazole; ten were switched to amphotericin B. CSF white blood cell count (WBC) began to decrease by day 13 of treatment. MRI findings include ventriculitis, leptomeningeal enhancement, infarct, hemorrhage and arachnoiditis. Serum voriconazole levels varied and CSF concentrations of voriconazole were approximately 50% that of serum. Exserohilum rostratum and Cladosporium spp. have been cultured.
Limitations: Observational study of an evolving outbreak. Not all exposed patients presented for evaluation. Follow-up is too short to determine final outcomes.
Conclusions: Meningitis after receipt of contaminated ESI has been diagnosed in a number of exposed patients presenting to one hospital. The majority of patients have improved on empiric voriconazole therapy. The full natural history and long term sequelae of this infection remain unknown at present.
Primary Funding Source: Unfunded.
