Sunday 18 March 2018

Outbreak of fungal central nervous system and osteoarticular infections

A new research article of interest:

A multistate outbreak of fungal central nervous system (CNS) infection and septic arthritis was detected in the United States in late September 2012. Over 700 patients who received epidural injections of methylprednisolone produced at a single compounding center (New England Compounding Center) developed meningitis with or without posterior circulation stroke and/or spinal or paraspinal infections, and more than 30 patients who received intraarticular injections of the same drug developed osteoarticular infections [1-3]. Exserohilum spp, a dematiaceous (brown-black) fungus, has been the most commonly identified fungus (picture 1).

The United States Centers for Disease Control and Prevention (CDC) issued recommendations for the diagnosis and management of patients affected by the outbreak. These recommendations can be found on the CDC website.

This outbreak highlights the importance of suspecting environmental contaminants as a cause of infection introduced by a potentially contaminated drug or other compound in patients with a suggestive clinical presentation. This is particularly relevant in patients who have received products prepared by compounding pharmacies, which have substantially less federal oversight than traditional pharmaceutical companies. (See 'Compounding pharmacies'below.)

The epidemiology, clinical manifestations, and diagnosis of fungal CNS and osteoarticular infections associated with the outbreak will be discussed here; the treatment of such infections is presented separately. Infections due to dematiaceous fungi and Aspergillus spp that are not associated with the outbreak are also discussed separately. (See "Outbreak of fungal central nervous system and osteoarticular infections in the United States: Treatment" and "Central nervous system infections due to dematiaceous fungi (cerebral phaeohyphomycosis)" and "Epidemiology and clinical manifestations of invasive aspergillosis", section on 'Central nervous system infection' and "Diagnosis of invasive aspergillosis".)

Posted by Dr. Tim Sandle

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