Earlier this month, the Centers for Disease Control and Prevention published the first comprehensive report on the fungal meningitis outbreak that has killed 12 and sickened 137. There is much news for us.
1.The report's lead author, Dr. Marion Kainer, and her group at the Tennessee Department of Health -- whom I know well -- must be congratulated. They followed up on a single case-report from a clinician and in less than 10 days, along with the CDC, pieced together a number of random meningitis cases, thereby identifying the New England Compounding Center as the source of the outbreak. Without such well-trained epidemiologists based at state health departments, it would have taken us weeks or even months before such a clear picture would have emerged. Why? Because fungal meningitis is not a reportable disease, and often when the spinal fluid cultures are negative, we doctors suspect it may be a virus causing the meningitis.
2.The report points out that the presentation of meningitis in these cases is very atypical. Often, in patients with meningitis we see severe headache, fever, and/or photophobia (sensitivity to light), as is often the case with bacterial and viral meningitis. But in these cases, patients only had a mild headache, only one-third have had a fever, and 10 percent have had photophobia -- all of which makes it difficult for the doctor to suspect or diagnose meningitis.
3.Another remarkable clinical finding is that nearly 1 in 5 patients presented with stroke-like symptoms. This is again unique to fungal meningitis unlike bacterial or viral meningitis. So clinicians who are seeing patients presenting to the emergency room with a stroke need to obtain a history from the patient to make sure they have not had any spinal steroid injections in the past six months.
4.Since the first case was noted to be the Aspergillus fungus, many clinicians assume that it is Aspergillus causing most of the cases of fungal meningitis. However the report notes that half of the initial cases had the fungus Exserohilum species growing in the spinal fluid. Many doctors, including me, were not aware of this fungus. In fact, if such a culture came back positive, without my knowledge of this epidemic I would have likely told the patient that the culture report was false with possibly a laboratory contamination. Yet, undoubtedly this fungus is a pathogen, and it is unclear if there may be other fungal pathogens, which are naturally occurring in plants and soil and which may have contaminated the steroid vials.
5.From the report, we learn that getting the spinal fluid is critical in making the diagnosis. Without the fluid cell count and culture, it is unclear if spinal infection has occurred. As an infectious disease doctor, I know the importance of sampling and culturing body fluid and tissue prior to starting treatment. In these cases, we need to know definitively if there is spinal infection, a local infection or no infection, because it impacts treatment. Unlike bacterial or viral, which have a short course of treatment -- seven to 14 days -- fungal meningitis requires therapy for three to six months, or possibly longer. Moreover, antifungal medicines have many more side effects compared to antibiotics.
6.The report hints at additional concerns. The illnesses from the tainted steroid are not just limited to meningitis. There are also cases of spinal osteomyelitis, bone infection and epidural abscesses, an infection surrounding the spinal cord sac and lumbar disc where the steroid was injected.
7.Interestingly, the list of acknowledgments at the end of the report is as long as the report. And this is important because it reassures me that this is a collaborative effort by extremely well-trained professionals. I recognized many names like Alfred DeMaria, my mentor from Massachusetts Department of Health, and John Jernigan from Centers for Disease Control and Prevention. We must be thankful for their dedication.
While this report reveals much, there is much more to come. We do not know how patients were treated or what their outcome was. Also, we do not know if there are any findings of infections (as determined by an MRI or spinal tap) in patients who have no clinical symptoms.
Future reports will surely answer these questions. For now, this tragic event underscores the success of our investment in the public health system.
For more by Manoj Jain, M.D., MPH, click here.
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