Case 1 — This is a 67‐year‐old woman with a history of hypertension, chronic bronchiectasis, and chronic lumbar back pain who regularly received epidural steroid injections that was admitted 9/22/12 with a 2‐week history of fevers up to 105°F, headache and photophobia. Initial lab results and studies are shown in Table 1. She was empirically placed on vancomycin, ceftriaxone, acyclovir, trimethoprim‐sulfamethoxazole and dexamethasone for empiric coverage of bacterial meningitis. She initially improved, with resolution of her symptoms; however, 4 days after admission, she had increasing somnolence and became unresponsive requiring intubation and transfer to the intensive care unit. Magnetic resonance imaging of the brain showed large artery occlusions in the posterior circulation, notably the basilar artery resulting in acute infarcts also involving the brainstem. The family requested care to be limited to comfort measures, and the patient died on hospital day 9. Polymerase chain reaction lab results from the Centers for Disease Control of the cerebrospinal fluid showed the presence of Exserohilum 10 days after her death. Case 2 — This is a 68‐year‐old woman with a history of diabetes, hypertension, asthma, and chronic back pain who underwent L3–L4 fusion in 2010 and regularly received epidural steroid injections who was admitted October 5, 2012, with a 1‐week history of headache, neck stiffness, and photophobia. Initial lab results are shown in Table 1. She was empirically placed on amphotericin B, voriconazole, meropenem, and vancomycin for empiric coverage of bacterial and fungal meningitis. She clinically improved, but had some mild hallucinations which resolved after decreasing her dose of voriconazole. She was discharged to home on hospital day 6.
The fungal meningitis outbreak in patients (including the 2 presented) who received contaminated methylprednisolone acetate began in mid‐September with knowledge of this infection becoming widespread around September 28, 2012, when 17,000 vials were recalled. As a result of the recognition of this outbreak and the concerted effort to make clinicians aware, many patients, including the second case, were promptly identified and appropriately treated, resulting in improved clinical outcomes. However, relatively little attention has been paid to addressing a root cause of this outbreak, steroid injections for chronic back pain. Studies show improved short‐term pain control with epidural injections, but these are chronic conditions necessitating a longer‐term approach.
Institution of public health reporting and information dissemination was critical to managing the complications of this outbreak; however, broader steps should be taken to critically evaluate the use of steroids in chronic pain.
|Case 1||WBC 750 (75% PMNs), glucose 32, protein 90, CrAg negative, arbovirus IgM panel negative, HSV PCR negative, cultures negative|
|Case 2||WBC 3460 (73% PMNs), glucose 43, protein 113, CrAg negative, cultures negative|
|WBC, white blood cells; PMN, polymorphonuclear cells; CrAg, Cryptococcal antigen; HSV, herpes simplex virus; PCR, polymerase chain reaction.|