Fungal Meningitis and Steroid Injections (cont.)

Medical Author:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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Medical Editor:

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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In Michigan, the state that has reported the highest number of fungal meningitis infections due to contaminated steroid injections, physicians are reporting that about one-third of 53 patients treated for the disease and sent home are now returning to the hospital with epidural abscesses. Epidural abscesses are collections of pus, usually due to a bacterial or fungal infection, that occur between the outer covering of the spinal cord and the spine; it may also occur between the outer covering of the brain and skull. The main symptoms of these infections are severe pain at the injection site; diagnosis is made by CT or MRI because the abscess is located so deep in the body it gives no visible sign of infection. If not treated quickly with appropriate antifungal or antimicrobial drugs and possibly surgical drainage of the pus, patients can develop weakness, paralysis, permanent nerve damage, osteomyelitis, meningitis, or death. This situation has been documented in a few patients in Tennessee also. Unfortunately, this newest noted "late occurring" complication may be found as more patients complete their treatment for fungal meningitis caused by a contaminated steroid injection.

There are now five aspects of this health-care-related fungal meningitis infection that are concerning. First, the infection may take a long time (from two to 28 days; some may take even more time) to begin to develop the symptoms listed above. Second, several of the patients developed strokes due to the infection; and third, the steroid medications suppress inflammation and may make the individual more susceptible to infectious agents. Fourth, fungal meningitis is difficult to treat and usually requires at least two antifungal drugs given intravenously over an extended time period (months). The last or fifth aspect is that a number of patients treated for fungal meningitis may return with an epidural abscess. Consequently, compounded drugs, especially those containing steroids that are contaminated with fungi or bacteria, are likely to be difficult to both diagnose and treat.

A map and graph of people by state with fungal meningitis or joint infections is constantly updated by the CDC. This CDC site is http://www.cdc.gov/hai/outbreaks/meningitis-map.html and has the most up-to-date statistics on morbidity (people diagnosed) and mortality (deaths) from these health-care-related diseases.

Drug compounding centers are not regulated by the high standards that drug producers must meet. Most compounding centers are regulated by state agencies and not by the stricter FDA rules that are applied to drug producers. This current outbreak of fungal meningitis, joint infections, and other infections such as epidural abscesses related to products used to treat patients is likely to change this "oversight or regulation" situation. Currently, several high-ranking politicians are demanding stricter regulations be set up for drug-compounding companies. The FDA commissioner, the NECC cofounder, and the director of the Massachusetts Board of Registration in Pharmacy are scheduled to meet with a congressional panel on Nov. 14, 2012. Confidence in compounded drugs can be brought back to the many doctors and patients who need to use them only if such incidences of contaminated drugs from compounding centers are substantially reduced or eliminated.

REFERENCES:

Calvan, Bobby Caina and Globe Staff. "Compounding Pharmacies Have Long Evaded the Tight Oversight Governing Established Drug Makers." The Boston Globe Oct. 29, 2012. <http://www.boston.com/business/news/2012/10/29/compounding-pharmacies-have-long-evaded-the-tight-oversight-governing-established-drug-makers/KCnU0fS75nFlsJSUoDroyI/story.html>.

United States. Centers for Disease Control and Prevention. "CDC Responds to Multistate Outbreak of Fungal Meningitis and Other Infections." Nov. 2, 2012. <http://www.cdc.gov/HAI/outbreaks/currentsituation/>.

United States. Centers for Disease Control and Prevention. "Multistate Meningitis Outbreak Investigation." Oct. 8, 2012. <http://www.cdc.gov/HAI/outbreaks/meningitis.html>.