October 1, 2012
Update on Meningitis Following a Multi-State Outbreak of Epidural Injections
The Centers for Disease
Control and Prevention, along with state health departments, are investigating a
multi-state outbreak of meningitis following epidural steroid injections (ESI)
of preservative-free methylprednisolone. Many of these cases developed stroke
in deep brain locations.
On September 18, 2012, the
Tennessee Department of Health was notified of a patient with culture-confirmed Aspergillus fumigatus meningitis following ESI at a Tennessee
ambulatorysurgical center. Subsequent outreach demonstrated nine additional
patients with clinically-diagnosed meningitis in Tennessee and North Carolina.
Symptoms of meningitis, including headache, stiff neck,and fatigue, developed
within one to four weeks post-injection. Five patients have developed additional
focal neurological deficits due to stroke in the base of the brain or brainstem.
All patients had a similar cerebrospinal fluid (CSF) profile with low glucose,
elevated protein and high, neutrophil-predominant white cell count; CSF cultures
on the nine subsequent patients are negative to date. Patients have generally
received antibacterial antibiotics without improvement and although steroids
have resulted in short term improvement in many patients clinical deterioration
has followed steroid cessation.
All patients received one or
more ESIs during July 30 to September 18, 2012. All patients received injections
of preservative-free methylprednisolone acetate solution from a single
compoundingpharmacy. In addition, all patients received subcutaneous injections
of lidocaine from a common manufacturer and skin prep with povidone-iodine from
another common manufacturer.
To understand the scope of
this cluster and identify possible etiologies, we are seeking information on
patients with clinical meningitis, other neurologic infection (epidural abscess,
spinal osteomyelitis, etc.) or cerebrovascular accident with symptom onset
within 1 month following epidural injections since July 1, 2012.
Some facilities may have
performed injections at other body sites, and because the source of these
infections is not yet known, clinicians are encouraged to remain alert for and
promptly report complications associated with these other types of
Because Aspergillus meningitis can be difficult to diagnose, clinicians should consider this
diagnosis in any patient presenting with similar signs and symptoms of
neurologic infection post-ESI. Diagnosis of Aspergillus meningitis should
be sought by evaluating CSF for Aspergillus (galactomannan) antigen;
fungal cultures of CSF should also be performed, preferably following
centrifugation concentration. Empiric treatment with amphotericin B or
voriconazole should be considered if Aspergillus meningitis is
Clinicians who learn of
suspected cases of clinical meningitis, other neurologic infection (i.e.
epidural abscess, spinal osteomyelitis, etc.) or cerebrovascular accident with
symptom onset within 1 month of epidural injection since July 1 2012, or who
have identified complications associated with other types of injections,are
asked to notify Dr. Joan Duwve, ISDH Chief Medical Officer, at
EPI Ex Document for more information