May 17, 2013
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Michigan reported half of spinal, paraspinal infection cases during meningitis outbreak

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Of the 320 paraspinal and spinal infections without meningitis associated with the national fungal meningitis outbreak, 167 of the cases (52%), as of May 6, were reported in Michigan, CDC researchers reported in Morbidity and Mortality Weekly Report.

The first fungal meningitis case was reported in September in Tennessee. During the fifth week of the outbreak, there were reports of localized spinal and paraspinal infections, including epidural abscesses, phlegmon, arachnoiditis, discitis and vertebral osteomyelitis. The outbreak has resulted in 741 reported cases of fungal meningitis and other fungal infections and 55 deaths in 20 states.

The outbreak was linked to contamination of vials of methylprednisolone acetate produced by the New England Compounding Center in Framingham, Mass. The first patient had a laboratory-confirmed Aspergillus fumigatus infection, but the most common fungus found was Exserohilum rostratum.

According to the report, there are several reasons why Michigan had such a high number of spinal and paraspinal infection, despite receiving only 13% of the potentially contaminated vials. Early experience with these infections prompted clinicians in some locations to offer spinal MRIs to patients who had received injections, but had no symptoms of infection. This may have led to increased case finding.

Another possible explanation is that the vials shipped to Michigan had higher levels or contamination, or the fact that a pain specialist in Michigan received the largest shipment of 5 mL vials to any single state.

“This outbreak has presented multiple challenges, including unknown incubation periods, a broader spectrum of clinical presentations than initially anticipated, latent disease and a wide range in the number of days from the last contaminated injection to the first positive MRI finding,” the researchers wrote. “Expanded MRI screening efforts might lead to additional diagnoses and improve case ascertainment, but such efforts should be considered along with the unknown balance of risks and benefits in treating patients on the basis of MRI findings alone.”

Disclosure: The researchers report no relevant financial disclosures.