CDC Update: Multistate Outbreak of Fungal Meningitis and Other Infections Associated with Contaminated Steroid Medication

HEALTH Advisory

Note: The following information was originally distributed via the CDC Health Alert Network (HAN) as follows:

Centers for Disease Control and Prevention (CDC)
Health Alert Network (HAN) Advisory

Update: Multistate Outbreak of Fungal Meningitis and Other Infections Associated with Contaminated Steroid Medication
 

This is an official CDC Health Advisory
Distributed via Health Alert Network
November 20, 2012, 15:00 ET (3:00 PM ET)
CDC HAN-00335-2012-11-20-ADV-N

Summary: The Centers for Disease Control and Prevention (CDC) continues to work closely with state public health departments on a multistate investigation of fungal meningitis and other infections among patients who received a methylprednisolone acetate (MPA) injection prepared by the New England Compounding Center (NECC) in Framingham, Mass.

This HAN notice provides updated information on the following:

• Epidural abscess and other clinical syndromes being diagnosed in exposed patients
• Diagnostic and treatment recommendations for clinicians

Background: As of November 19, 2012, a total of 490 cases, which includes 34 deaths, have been reported in 19 states (see CDC’s website www.cdc.gov/hai/outbreaks/meningitis

for up-to-date information about case count and distribution by state). Exserohilum rostratum continues to be the predominant fungus identified in patients and confirmed by the CDC laboratory.

Clinical Syndromes Reported to CDC

Currently, more than 7 weeks after the three implicated lots of MPA1 were recalled, CDC continues to receive reports of fungal infection in exposed patients. Previously, the majority of new cases reported to CDC were patients with fungal meningitis following injection.

Although cases of fungal meningitis continue to be reported, CDC has recently observed an increase in the number of patients presenting with evidence of epidural abscess, phlegmon, discitis, vertebral osteomyelitis, or arachnoiditis at or near the site of injection. These complications have occurred in patients with and without evidence of fungal meningitis.

Of the 91 cases reported to CDC since November 4, 2012, a total of 26 (29%) were classified as meningitis, 61 (67%) had spinal or paraspinal epidural abscess or osteomyelitis, 2 (2%) had peripheral joint infection, and 2 (2%) had more than one condition (Figure 1).

FIGURE 1

Note: Data presented in Figure 1 are preliminary and subject to change. Additional patients may ultimately meet multiple case definitions (e.g., meningitis and osteomyelitis/abscess) as more time elapses and additional information is provided to CDC. Reporting dates to CDC may lag behind onset dates.

Diagnostic and Treatment Guidance

As a reminder, CDC’s current diagnostic and treatment guidance

addresses management of patients with epidural abscess or other complications at or near the injection site. These localized infections may occur in isolation or in patients previously diagnosed with fungal meningitis. Although patients with these localized infections frequently have new or worsening back pain, symptoms may be mild or clinically difficult to distinguish from the patient’s baseline chronic pain. Based on current information, CDC recommends the following diagnostic protocol:

• In patients with new or worsening symptoms at or near the injection site, physicians should obtain an MRI with contrast of the symptomatic area(s), if not contraindicated. This recommendation also applies to patients being treated for meningitis. In some cases, radiologic evidence of abscess or phlegmon has become apparent on repeat MRI studies performed subsequent to an initially normal imaging procedure. Clinicians should therefore have a low threshold for repeat MRI studies in patients who continue to have symptoms localizing to the site of injection, even after a normal study. However, the optimal duration between MRI studies is unknown.

• CDC has received reports of patients being treated for fungal meningitis who had no previous evidence of localized infection at the site of injection, but who were subsequently found to have evidence of localized infection (e.g., epidural abscess, phlegmon, discitis, vertebral osteomyelitis, or arachnoiditis) on imaging studies. Therefore, in patients being treated for meningitis, even in the absence of new or worsening symptoms at or near the injection site, clinicians should strongly consider obtaining an MRI of the injection site approximately 2-3 weeks after diagnosis of meningitis. Early identification of new disease may facilitate additional specific interventions (e.g., drainage) and provide information for measuring effectiveness of therapy thereafter.

• For patients demonstrated to have epidural abscess, phlegmon, discitis, vertebral osteomyelitis, or arachnoiditis, early consultation with a neurosurgeon to discuss  whether surgical management, including debridement, is warranted in addition to antifungal therapy (for information about antifungal therapy, see Interim Treatment Guidance for Central Nervous System and Parameningeal Infections Associated with Injection of Contaminated Steroid Products)
  .

CDC continues to gather data from existing and newly reported cases of infection and will use this information to inform updates to existing guidance. Healthcare professionals with patients under their care should check CDC’s website

for the most up-to-date clinical guidance because information is subject to change.

 NECC lots of methylprednisolone acetate (PF) 80mg/ml:

•       Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #05212012@68, BUD 11/17/2012
•       Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26, BUD 12/26/2012
•       Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51, BUD 2/6/2013

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

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The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Computer Generated Neck Pain

I've been sitting at the computer for some time now and I'm experiencing neck pain. I should know better!! Neck pain is a common symptom for people who spend considerable amounts of time on a computer but does it have to be? Absolutely not.

Many factors contribute to feeling pain but all are controllable. Neck pain results from strains that occur to the muscles and ligaments supporting our spine when the spine is not maintained in a neutral position for an extended period of time. This is particularly true of spines that are already compromised by previous injury, arthritis, misalignment, scoliosis...etc.

Your head weighs approximately 8-12 lbs. It sits atop a column of 7 stacked vertebrae making up the neck. Between each adjacent vertebra, a cushion-like tissue called a disc acts to absorb the weight of your head onto that portion of our spine. Our neck spinal column normally curves forward creating a "C" or reversed "C" depending on what side of a person you're looking at. This allows the spine to bend to further absorb the weight of your head. The ligaments attach the vertebrae together to help maintain them in place. We have a variety of muscles that attach not only vertebrae to vertebrae but also vertebrae to other bones such as our shoulder blades, collar bones, skull...etc. They act as guide wires to help balance the head on the spinal column.

Neck pain is most commonly caused, initially, by these muscles getting fatigued. When we maintain good posture, our head balances on this spinal column with very little strain to these supporting muscles. However, when we look down at a keyboard for an extended time or we slouch causing our head to extend back to see the screen, those same muscles must work much harder to prevent your head from falling off your shoulders because it has veered from its center of gravity.

The concept is best demonstrated by attaching a bowling ball (your head) to the top of a broomstick (your neck spinal column called the cervical region). If you then align it perfectly with its center of gravity, you could balance it on the tip of your finger. Let it fall away from that center of gravity and you must use considerable muscular effort by grabbing it with both hands to prevent it from falling further from its center of gravity. In the same way, look down at the keyboard and your neck muscles have to work much harder to keep your head from falling further which eventually leads to fatigue and pain.

So, what's a person to do?

Maintain good posture to minimize fatigue. Take mini breaks to reduce sustained positions that may lead to muscle fatigue. I recommend getting up every 15 mins to at least walk around the desk and stretch briefly before continuing to work at your desk. Any interruption of that prolonged position will help. Pay attention to proper ergonomics as well. Also, exercise regularly to "burn off" that building muscle tension.

Dr Rick Jardon