News & Press: Patient Safety

UPDATE: Multi-State Outbreak of Meningitis Following Epidural Injections

Monday, October 1, 2012  
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Brief Summary: Ten patients with meningitis, many with accompanying stroke in deep brain locations, have been reported following epidural steroid injection (ESI) including nine in Tennessee and one in North Carolina. Please report 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 to Rachel Smith at the Centers for Disease Control and Prevention (CDC) at vih9@cdc.gov / 404-639-7738.

Description: 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 ambulatory surgical 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 compounding pharmacy. 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.

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 sent, preferably following centrifugation concentration. Empiric treatment with amphotericin B or voriconazole should be considered if Aspergillus meningitis is suspected.

State and local health departments are asked to disseminate this advisory widely to appropriate clinicians in their respective jurisdictions, including emergency room and infectious disease physicians. Public health officials 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, are asked to notify their respective state health departments and contact Rachel Smith at CDC: vih9@cdc.gov / 404-639-7738.

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