Outbreak of fungal central nervous system and osteoarticular infections in the United States: Treatment
- Anna R Thorner, MD
Anna R Thorner, MD
- Co-Director, Editorial Projects — UpToDate
- Deputy Editor — Infectious Diseases
- Assistant Professor of Medicine, Part-time
- Harvard Medical School
- Section Editors
- Carol A Kauffman, MD
Carol A Kauffman, MD
- Section Editor — Fungal Infections
- Professor of Internal Medicine
- University of Michigan Medical School
- Veterans Affairs Ann Arbor Healthcare System
- Kieren A Marr, MD
Kieren A Marr, MD
- Section Editor — Compromised Host Infections; Fungal Infections
- Professor of Medicine and Oncology
- Johns Hopkins University School of Medicine
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 intra-articular injections of the same drug developed osteoarticular infections [1,2]. 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) issued recommendations for the management of patients affected by the outbreak. These recommendations can be found on the CDC website.
The treatment of patients with fungal CNS infection or septic arthritis associated with the outbreak will be reviewed here; the epidemiology, clinical manifestations, and diagnosis of such infections are presented separately. The treatment of 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: Epidemiology, clinical manifestations, and diagnosis" and "Central nervous system infections due to dematiaceous fungi (cerebral phaeohyphomycosis)" and "Treatment and prevention of invasive aspergillosis".)
The United States Centers for Disease Control and Prevention (CDC) defined a probable case associated with the 2012 outbreak as a person who received an injection with methylprednisolone acetate that was definitely or likely produced by the New England Compounding Center (NECC) after May 21, 2012, and who developed any of the following syndromes :
●Meningitis of unknown etiology following epidural or paraspinal injection. Clinically diagnosed meningitis is defined as the presence of one or more of the following symptoms: headache, fever, stiff neck, or photophobia and a cerebrospinal fluid (CSF) profile showing pleocytosis (>5 white blood cells, adjusting for the presence of red blood cells by subtracting 1 white blood cell for every 500 red blood cells), regardless of glucose or protein concentration.
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