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Published Date: 2012-10-11 15:45:54
Subject: PRO/EDR> Aspergillus meningitis - USA (09): Exserohilum
Archive Number: 20121011.1337615

ASPERGILLUS MENINGITIS - USA (09): EXSEROHILUM
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[1] CDC: _Exserohilum_ predominant mold
Date: Thu 11 Oct 2012
Source: CDC [edited]
http://www.cdc.gov/hai/outbreaks/meningitis.html

As of 10 Oct 2012, CDC's fungal disease laboratory has confirmed the presence of the fungus exserohilum in 10 people with meningitis and the fungus aspergillus in one person with meningitis.

Clinicians should continue to contact patients who have received medicines associated with 3 lots of preservative-free methylprednisolone acetate (80mg/mL) from the New England Compounding Center (NECC) that were recalled on 26 Sep 2012, 2012. The potentially contaminated injections were given starting 21 May 2012.

CDC's guidance to patients has not changed as a result of the expanded voluntary recall of all NECC products, announced 6 Oct 2012. Patients who feel ill and are concerned about whether they received a medication from one of the NECC products recalled on 26 Sep 2012 should contact their physician.

Onset of symptoms is typically 1 to 4 weeks following injection, but there are also reports of shorter and longer periods of time between injection and onset of symptoms.

At-a-glance
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Status: ongoing investigation
Infection: fungal meningitis
Facility type: outpatient setting
Case count: 170
States: 11
Deaths: 14

A map of the states affected can be found at:
http://www.cdc.gov/hai/outbreaks/meningitis-map.html.

State / Case Count / Deaths
Florida / 7 / 2
Idaho / 1 / 0
Indiana / 21 / 1
Maryland / 13 / 1
Michigan / 39 / 3
Minnesota / 3 / 0
New Jersey / 2 / 0
North Carolina / 2 / 0
Ohio / 3 / 0
Tennessee / 49 / 6
Virginia / 30 / 1
TOTALS = 170 cases with 14 deaths

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[2] Tennessee health commissioner: Exserohilum predominant mold
Date: Tue 9 Oct 2012
Source: Examiner.com [edited]
http://www.examiner.com/article/tennessee-reports-two-more-deaths-exserohilum-is-the-primary-fungus-implicated

During his daily statement, Tennessee Health Commissioner John Dreyzehner, MD, MPH, made several key points concerning the outbreak in Tennessee and in general.

He noted that the primary fungus infecting patients in Tennessee is exserohilum, a mold rarely seen in human infections. It is a cosmopolitan fungus inhabiting plant material, particularly grasses and soil. Dr Dreyzehner points out that currently used antifungal treatments are effective against this fungus.

In addition, he says that the incubation time for the infection may be significantly longer than originally suspected. What was initially reported to be an incubation time of up to a month is now believed it may possibly be up to 3 months.

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[3] CDC: Septic arthritis and suspect case definitions added
Date: Wed 10 Oct 2012
Source: CDC [edited]
http://www.cdc.gov/HAI/outbreaks/clinicians/casedef_multistate_outbreak.html

Case definitions for meningitis and septic arthritis
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A person who received an injection with methylprednisolone acetate produced by the New England Compounding Center (NECC) who has developed any of the following:

- fungal meningitis or non-bacterial and non-viral meningitis (1) of subacute onset, following epidural injection on and after 21 May 2012;
- basilar stroke following epidural injection after 21 May 2012, who has not received a diagnostic lumbar puncture (2);
- evidence of spinal osteomyelitis or epidural abscess at the site of injection following epidural or sacroiliac injection after 21 May 2012;
- septic arthritis or osteomyelitis of a peripheral joint (for example, knee) diagnosed following joint injection after 21 May 2012.

1. Clinically diagnosed meningitis meaning one or more of the following symptoms: headache, fever, stiff neck, or photophobia and a cerebrospinal fluid (CSF) profile showing pleocytosis (>5 white blood cells, adjusting for presence of red blood cells) regardless of glucose or protein levels.
2. These people, if possible, should have a lumbar puncture.
3. Clinically diagnosed septic arthritis meaning new or worsening pain with presence of effusion or new or worsening effusion.

Suspect case:
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A person who has developed an infection of a normally sterile site (for example, blood, CSF, pleural fluid, peritoneal fluid, pericardial fluid, surgical aspirate, bone, joint fluid, or internal body site [for example, lymph node, brain]) following use of a product labeled as sterile prepared by the New England Compounding Center (NECC).

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[4] Role of antifungal prophylaxis in asymptomatic patients
Date: Wed 10 Oct 2012
Source: CDC [edited]
http://www.cdc.gov/HAI/outbreaks/clinicians/gudance_antifungal_prophylaxis.html

At this time, CDC does not recommend initiation of antifungal prophylaxis in exposed patients who are asymptomatic. These patients should be closely monitored for development of symptoms, with a low threshold for performing lumbar puncture should the patient become symptomatic.

In addition, CDC does not recommend empiric antifungal therapy for symptomatic patients who have normal cerebrospinal fluid laboratory examination. These patients should be closely monitored and re-evaluated should their symptoms worsen. Should the patient have progression of symptoms, a lumbar puncture should be repeated immediately.

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[It would be useful to know the date of administration of the contaminated corticosteroid and the date of initial onset of symptoms as well as the cell count, chemistries, and time to positive culture in documented cases. As well, the species of _Aspergillus_ mold has not been reported but cases with _Exserohilum_ species seem to be commoner than those with aspergillus.

As the number of cases continues to rise, a 2nd mold, exserohilum, has been reported to be the dominant organism. This environmental organism is much less common as a human pathogen than aspergillus. This agent is one of the molds associated with phaeohyphomycosis (McGinnis MR, Rinaldi MG, Winn RE. Emerging agents of phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum. J Clin Microbiol. 1986;24:250-259). A more definitive discussion on exserohilum will occur in the next posting on this expanding outbreak.

This is the 1st time CDC has added a case definition for septic arthritis although no cases related to joint injection of the contaminated corticosteroid have yet occurred. The numbers of joint injections compared with the numbers of injections into the lumbar spinal canal have not been reported.

Related to the date of reporting (not date of onset), the number of cases, number of states involved and deaths is:

Date of report / Cases / States / Deaths
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02 Oct 2012 / 12 / 2 / 2
04 Oct 2012 / 26 / 5 / 4
05 Oct 2012 / 35 / 5 / 5 (9 more cases, 1 more death)
06 Oct 2012 / 64 / 9 / 7 (29 more cases, 2 more deaths)
07 Oct 2012 / 91 / 9 / 7 (27 more cases, 0 more deaths)
08 Oct 2012 / 101 / 9 / 8 (10 more cases, 1 more death)
09 Oct 2012 / 119 / 10 / 11 (18 more cases, 3 more deaths)
10 Oct 2012 / 137 / 10 / 12 (28 more cases, 1 more death)
11 Oct 2012 / 170 / 11 / 14 (33 more cases, 2 more deaths)

Case fatality rate = 8.2 per cent - Mod. LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1hiS.]

See Also