Outbreak of fungal central nervous system and osteoarticular infections in the United States: Epidemiology, clinical manifestations, and diagnosis

INTRODUCTION

A multistate outbreak of fungal central nervous system (CNS) infection and septic arthritis was detected in the United States in late September 2012. Currently, over 700 patients who received epidural injections of methylprednisolone produced at a single compounding center (New England Compounding Center) have developed meningitis with or without posterior circulation stroke and/or spinal or paraspinal infections and more than 30 patients who received intra-articular injections of the same drug have developed osteoarticular infections [1-3]. Exserohilum spp, a dematiaceous (brown-black) fungus, has been the most commonly identified fungus (picture 1).

The United States Centers for Disease Control and Prevention (CDC) has issued recommendations for the diagnosis and management of patients affected by the outbreak. These recommendations can be found on the CDC’s web site and are expected to be updated frequently during the outbreak investigation. Our recommendations are in keeping with those of the CDC.

The epidemiology, clinical manifestations, and diagnosis of fungal CNS and osteoarticular infections associated with the outbreak will be discussed here; the treatment of such infections is presented separately. Infections due to dematiaceous fungi and Aspergillus spp that are not associated with the outbreak are also discussed separately. (See "Outbreak of fungal central nervous system and osteoarticular infections in the United States: Treatment" and "Central nervous system infections due to dematiaceous fungi (cerebral phaeohyphomycosis)" and "Epidemiology and clinical manifestations of invasive aspergillosis", section on 'Central nervous system' and "Diagnosis of invasive aspergillosis".)

EPIDEMIOLOGY AND PUBLIC HEALTH INFORMATION

A multistate outbreak of fungal central nervous system (CNS) and osteoarticular infections was detected in the United States in late September 2012 [1,2,4-7]. Currently, over 700 patients who received epidural injections of methylprednisolone have developed meningitis with or without posterior circulation stroke and/or spinal or paraspinal infections, and more than 30 patients who received intra-articular injections of the same drug developed osteoarticular infections [3]. Exserohilum spp, a dematiaceous (brown-black) fungus, has been the most commonly identified fungus (picture 1) [6].

In an early review of cases, the median age of 386 affected patients was 64 years (range 16 to 92 years); 60 percent were female [6]. A total of 35 patients (9 percent) had underlying immunosuppression. It appears that the period of greatest risk for the development of fungal meningitis was during the first six weeks (42 days) after receiving an epidural or paraspinal injection with contaminated methylprednisolone [8].

                     

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Literature review current through: May 2013. | This topic last updated: Jun 11, 2013.
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