Fast action, individualized treatment necessary in fungal meningitis outbreak

A research letter and an opinion piece published last week in Annals of Internal Medicine provide details and guidance on caring for patients in the current outbreak of fungal meningitis due to contaminated methylprednisolone.

The research letter details the case of one of the index patients in the outbreak, a 51-year-old woman who sought care in the emergency department for a headache after receiving a steroid injection in her neck. The patient had not received previous injections, was not immunocompromised, and was not taking any long-term medications. She was discharged after a normal physical exam and head CT but returned the next day with neurological symptoms and was hospitalized. Her condition deteriorated rapidly, and she died on hospital day 10.

Exserohilum species was found in the patient's cerebrospinal fluid, and autopsy revealed severe damage to her brain and spinal cord. The authors stressed that this case demonstrates the aggressive, invasive nature of Exserohilum species as well as its short incubation time. Rapid recognition and treatment are necessary, they said, to limit morbidity and mortality.

The opinion piece was written by a physician who treated patients during another fungal meningitis outbreak, involving Exophiala dermatitidis and also due to contaminated methylprednisolone, in 2002. Voriconazole, which was used successfully in the 2002 outbreak, appears to be the logical drug of choice in the current outbreak as well, but the author stressed that exact dosing, outcomes, and drug level monitoring have not been determined and must be based on expert opinion.

“Individual physicians cannot wait for definitive answers and must act decisively at an early stage of infection,” he wrote. Appropriate duration of therapy, use of empirical voriconazole and screening methods are also unknown and management will need to be individualized according to each patient's circumstances, he said.

The author reminded readers about the “importance of sterility and the powerful disease-producing interactions between corticosteroids and fungi” and stressed that regulation of pharmacy compounding at state and national levels will need to be revisited.

“Productive discourse between pharmacy societies, the FDA, the pharmaceutical industry, and the legislatures can hopefully balance the demand for individualized, designer products for patient care against the risks for outbreaks that cause suffering and death and that erode trust in public health systems,” he wrote. “Otherwise, this will surely happen again.”

Updated information on the outbreak from the CDC and the FDA is also available online.