CDC stresses continued vigilance for fungal meningitis
As the case count and death count continues to rise, the Centers for Disease Control and Prevention (CDC) is cautioning physicians and patients to continue their vigilance for signs of fungal meningitis. To date, 285 cases have been reported, including 23 deaths in 16 states. A total of 14,000 individuals in 23 states received methylprednisolone acetate steroid injections produced by the now-shuttered New England Compounding Company (NECC). All of them are still at risk for fungal meningitis from a contaminated vial.
On October 18, researchers at Duke University (Durham, NC), published an article online that describe a fungal meningitis outbreak that occurred a decade ago. Five individuals were infected and one died. One individual did not develop symptoms until 152 days after receiving an injection. Thus, exposed individuals cannot breathe easy for another four months. The CDC count of 14,000 includes individuals who received injections into their joints. Those patients are at less risk of a serious health problem. To date, none of them have died. Fungal infections come on slowly and are difficult to diagnose. Symptoms include fever, headache, stiff neck, nausea and vomiting, photophobia (sensitivity to light), and altered mental status. These symptoms can also occur with less serious infections, such as the flu.
It is not feasible to treat all exposed individuals because the treatment is involved, costly, and associated with significant side effects. The previous outbreak has provided some guidelines for treating the current, much larger outbreak; however, CDC officials note that they are currently navigating uncharted territory; thus, they are uncertain how responsive currently-infected individuals will be to therapy. Most individuals who contracted a fungal meningitis infection had a compromised immune system secondary to AIDS, cancer, burns or organ transplantation.
The Duke researchers note that in cases without certainty in diagnosis, follow-up and treatment must be conducted on a case-by-case basis. They note that voriconazole is the logical antifungal drug of choice for initial treatment of fungal meningitis pending more definitive information. It penetrates the central nervous system compartments and was successfully used to treat patients in the 2002 outbreak. They caution, however, that at this time, exact dosing, correlation of in vitro (laboratory) and in vivo (in a living human or animal) testing for outcome, and monitoring of drug levels can only be based on educated opinion. They note that individual physicians cannot wait for definitive answers and must act decisively at an early stage of infection.
They stress that “patients will need to be followed closely and management refined in real-time. The details of the epidemiology, including the attack rate, remain unclear. The natural history of resultant infections is only now coming into focus, and the manner by which exposed patients should be followed and managed is a work in progress. Unfortunately, the incubation period for these infections, based on prior experience, may extend to months after exposure. Therefore, exposed patients will need to be followed for a long time. The appropriate duration of therapy is similarly unknown, as are such questions as whether to screen with lumbar puncture or joint aspiration and appropriate use of empirical voriconazole. The bottom line is that management will need to be individualized for patients for some time to come.”
Map credit: CDC