What we know and don’t know about fungal meningitis outbreak
In a new perspective piece being published Online First tonight in Annals of Internal Medicine, a physician recalls lessons learned from treating patients affected by the 2002 outbreak of Exophiala (Wangiella) dermatitidis meningitis or arthritis related to contaminated, injectable coticosteroids prepared from a compounding pharmacy.
According to the author, the lessons he learned in 2002 are applicable to the current outbreak. He warns that compounding of preservative-free corticosteroids requires meticulous sterility to ensure lack of fungal contamination. Without this sterility, fungus grows aggressively.
As seen with the current cases, once injected, the fungus can travel through the body’s tissues rapidly, leading to invasive mycosis. However, the incubation period from exposure to disease could be up to six months, so exposed patients will need to be followed for a long time. While there were many people exposed to the fungus in 2002, all but one fatal case were successfully treated with voriconazole.
Treatment decisions should be made on a case-by-case basis, but the author writes that evidence from the previous outbreak suggests voriconazole as the logical antifungal drug for initial treatment. Due to the aggressive and deadly nature of the disease, it is important for physicians to act decisively and early.
The author warns that these outbreaks will happen again if pharmacy societies, the FDA, and the pharmaceutical industry do not work together to regulate pharmacy compounding.
What is fungal meningitis?
Fungal meningitis is inflammation of the lining that surrounds and protects your brain and spinal cord. The inflammation is caused by a fungal infection and can be life-threatening.
What causes fungal meningitis?
Fungus germs live in soil. It is not easily spread from person to person. You may be more likely to get fungal meningitis if you have other medical problems, such as diabetes, cancer, or HIV. You are also more likely to get it if you take certain medicines over a long period of time.
What are the signs and symptoms of fungal meningitis?
- Severe headache
- High fever
- Nausea or vomiting
- Stiff neck or neck pain
- Eye pain when you look into bright lights
- Sleepiness or confusion.
How is fungal meningitis diagnosed?
CT scan: This test is also called a CAT scan. An x-ray and computer are used to take pictures of your skull and brain. You may be given dye, also called contrast, before the test. Tell the caregiver if you are allergic to dye, iodine, or seafood.
Lumbar puncture: This procedure may also be called a spinal tap. During a lumbar puncture, you will need to lie very still. Caregivers may give you medicine to make you lose feeling in a small area of your back. Caregivers will clean this area of your back. A needle will be put in, and fluid removed from around your spinal cord. The fluid will be sent to a lab for tests. The tests check for infection, bleeding around your brain and spinal cord, or other problems. Sometimes medicine may be put into your back to treat your illness.
MRI: This scan uses powerful magnets and a computer to take pictures of your brain. It will also take pictures of the blood vessels and structures in your head. You may be given dye, also called contrast, before the test. Tell caregivers if you are allergic to dye, iodine, or seafood. Remove all jewelry, and tell caregivers if you have any metal in or on your body. Metal can cause serious injury. Tell caregivers if you cannot lie still or are anxious or afraid of closed spaces.
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Fungal meningitis may be caused by several types of fungus, for example:
Candida albicans -
This is the fungus which causes thrush.
In very rare cases it can cause a dangerous form of meningitis, especially in premature babies with very low birth weight.
Cryptococcus neoformans -
This fungus causes most cases of fungal meningitis.
Cryptococcal meningitis is caused by a yeast or fungus commonly found in the environment, including the soil, everywhere in the world.
Generally, only people with deficiencies of the immune system including inherited immune conditions, HIV, cancer or, more rarely, diabetes develop serious cryptococcal infection, such as meningitis.
Symptoms may include headache, fever, nausea, vomiting, stiff neck, dislike of bright lights, changes in mental state and hallucinations. Symptoms do not come on suddenly as with acute bacterial meningitis but appear gradually.
Treatment is with antifungal medication, for instance or amphotericin B, flucytosine and fluconazole. Many patients will need “maintenance therapy” - which means they will have to continue taking medication indefinitely.
Histoplasma - This fungus is common and harmless in people with functioning immune systems, but can cause meningitis and other invasive diseases in immuno-deficient patients.
Megan Hanks
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215-351-2656
American College of Physicians