Elusive Meningitis Outbreaks - by Denise Grady

Meningitis Cases Are Linked to Steroid Injections in Spine

By Denise Grady,

The New York Times, October 2, 2012

Dr. April Pettit, an infectious diseases specialist at Vanderbilt University, was worried about her patient. He had been ill with meningitis* for two weeks, he was not getting better, and she could not figure out why. Antibiotics, the usual treatment, were not helping. Bacteria, the usual suspects, could not be found.

On the morning of Sept. 18, as she and a colleague were examining the patient and talking to his family, a pager buzzed. It was the hospital lab, with an answer at last — but a troubling one.

A culture of the patient’s spinal fluid had revealed a fungus, Aspergillus. The patient was so ill that he could no longer communicate, so Dr. Pettit spoke to the family.

“I told them it was a very unusual cause of meningitis in healthy people, and that we needed to try to figure out how he got this infection,” she said.

Had he done anything unusual in the weeks before he became ill? She asked.

The answer alarmed her. He had had a steroid injection in his spinal area to relieve back pain — a common treatment, administered to millions of people in the United States every year.

Dr. Pettit called the State Health Department.

She is now credited with being the clinician who recognized the “index case” in what has become a frightening outbreak of meningitis that has killed two people and sickened 12 others who also received steroid injections in their spines for pain. Doctors suspect that the steroid medicine was contaminated with the fungus. The meningitis does not spread from person to person.

Officials said it was not possible to predict the extent of the outbreak yet. Thirteen of the patients have been in Tennessee, and one in North Carolina. Two of the cases were new as of Tuesday, and health officials have said that there could be more cases and that other states could be affected.

“I don’t think we’ve identified all the cases that will be identified,” said Dr. David Reagan, the chief medical officer for the Tennessee Health Department.

Dr. Pettit’s patient was one of the two who died.

The Tennessee patients were treated at the Saint Thomas Outpatient Neurosurgery Center in Nashville, which was closed on Sept. 20. Center staff members notified more than 700 patients who received injections of the suspect drug. Another Tennessee clinic, the Specialty Surgery Center in Crossville, also received shipments of the possibly contaminated drug and was notifying patients.

Health officials emphasized that the problem appeared to come from the medication and not the clinics themselves, and that the clinics had immediately cooperated by notifying patients and, in the case of Saint Thomas, shutting down when the outbreak was recognized. But the officials have released few details about the source of the drug, saying the investigation was continuing.

All the patients who became ill were treated with one or more injections between July 30 and Sept. 18, and the incubation period — the time between exposure and when the patient gets sick — has ranged from seven days to about four weeks. That means that some patients may become ill in the next few weeks. Symptoms can include headache, dizziness, fever, loss of balance and slurred speech.

At a news conference on Tuesday, state health officials said some of the patients were recovering, but some were in critical condition.

The outbreak has led to a nationwide recall of the drug that all the patients received. The drug, preservative-free methylprednisolone acetate, was prepared by one compounding pharmacy, a pharmacy that prepares drug mixtures or solutions for hospitals and clinics. Health officials have declined to name the pharmacy or release lot numbers of the drug, but a spokesman for the Centers for Disease Control and Prevention said that all of the suspect lots had been recalled and that the pharmacy had stopped producing the medication.

Scientists are also testing other medications used in giving the spinal injections, like numbing agents and antiseptic wipes. They say the cause has not been determined for sure.

The treatments are called lumbar epidural steroid injections, but they are not the same as the epidurals commonly given to women for childbirth or Caesarean sections — something that health officials wanted to make clear to avoid creating alarm among women who have recently given birth.

Dr. William Schaffner, the chairman of preventive medicine at Vanderbilt, said that this type of fungal meningitis was serious and difficult to treat, and that the C.D.C. had convened an expert panel to help determine the best treatment. The disease can also be difficult to diagnose, because unlike other types of meningitis, it can cause strokes, and when a patient has stroke symptoms, doctors may not look for an infection as well. In addition, the organism can be difficult to grow in cultures of spinal fluid from patients, making the diagnosis even more of a challenge.

Detecting and treating the disease as early as possible gives the best chance of curing it, Dr. Schaffner said, so getting the word out to alert both doctors and patients to the symptoms is important.

He said that he understood the investigators’ reluctance to name the drug maker or provide full details until the investigation is finished, but that the outbreak and its link to the steroid medication have caused quite a bit of worry among both doctors and patients about whether other steroid preparations are safe.

“We have had many concerns expressed in our own institution,” he said. “Providers say, ‘Can we continue to use the steroids sent to us by our own pharmacy?’ ”

Others doctors also wanted more information. Dr. Christopher Standaert, a specialist in spinal and neuromusculoskeletal care at the University of Washington in Seattle, and a spokesman for the North American Spine Society, said he hoped that health officials would release the name of the product, the manufacturer and the lot numbers thought to be involved in the outbreak so that clinics could make sure it was not on their shelves.

“That would help the spine community,” he said. “The rest of us would like to know. It would be nice if they told the hospitals.”

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* Per Kristina Krohn, MD, (University of Minnesota) : Initially, meningitis symptoms may resemble the flu, with worsening headache, vomiting, and a sudden high fever (over 101.3). Over hours to days, patients may develop difficulty thinking, a stiff neck, sensitivity to light and may fall into a coma.  Meningococcal disease, caused by the bacteria Neisseria meningitidis, infects the lining around the brain. Once someone becomes sick, without treatment it is always fatal -- even with treatment, up to a third of patients die, Fielding said. There is a vaccine that can prevent illness from meningitis…. The bacteria is [also generally] spread by close contact – such as kissing, or sharing a toothbrush, a cigarette or even a coffee cup.  
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Update (May 6,2013): The Center for Disease Control in Atlanta (CDC) continues to receive reports of patients presenting with paraspinal/spinal infections (e.g., epidural abscess, phlegmon, discitis, vertebral osteomyelitis, or arachnoiditis at or near the site of injection). These syndromes have occurred in patients with and without evidence of fungal meningitis. For details, please go to: http://www.cdc.gov/hai/outbreaks/meningitis-map-large.html