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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. Over 700 patients who received epidural injections of methylprednisolone produced at a single compounding center (New England Compounding Center) developed meningitis with or without posterior circulation stroke and/or spinal or paraspinal infections, and more than 30 patients who received intraarticular injections of the same drug 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 Web site. Our recommendations are in keeping with those of the CDC.

A separate outbreak of skin and soft tissue infections in patients who received intramuscular injections of methylprednisolone produced by another compounding pharmacy was detected in the United States in May 2013 [4,5] (see 'Main Street Family Pharmacy outbreak' below). Both outbreaks highlight the importance of suspecting environmental contaminants as a cause of infection introduced by a potentially contaminated drug or other compound in patients with a suggestive clinical presentation. This is particularly relevant in patients who have received products prepared by compounding pharmacies, which have substantially less federal oversight than traditional pharmaceutical companies. (See 'Compounding pharmacies' below.)

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 [1,2,6-9]. Over 700 patients who received epidural injections of methylprednisolone developed meningitis with or without posterior circulation stroke and/or spinal or paraspinal infections, and more than 30 patients who received intraarticular 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) [8,10,11].

                       

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Literature review current through: Mar 2014. | This topic last updated: Mar 12, 2014.
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