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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 injections.


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 suspected. 


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 317-233-7164.

EPI Ex Document for more information



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