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The First Meningitis Patient, And The Medical Mystery Of The Black Mold

Exserohilum rostratum (Wikimedia Commons)
Exserohilum rostratum (Wikimedia Commons)

The medical detective story of how Vanderbilt doctors figured out the link between tainted steroid injections and life-threatening meningitis came out almost three weeks ago — but now you can read the full (and frightening) clinical details of that "index case" in The New England Journal of Medicine here. 

The authoritative account includes the disturbing details of a man in his fifties who suddenly went into rapid decline a month after he had a spinal steroid injection. He comes in with "nausea, malaise, fatigue, chills, and decreased appetite." Despite antibiotics, his pain worsens and he becomes "agitated, with incomprehensible speech." He's treated with more drugs, but by his sixth day in the hospital, he's having "intermittent staring spells, and a transient right facial droop." The next day, the lab identifies the fungus Aspergillus and he is treated for it, but to little avail.

On hospital day 11, the patient abruptly became unresponsive, with rhythmic shaking of the head that was consistent with seizure activity. He was intubated and mechanical ventilation was initiated. A head CT scan showed intraventricular hemorrhage involving the lateral ventricles, subarachnoid hemorrhage in the perimesencephalic cistern, and worsening hydrocephalus.

The man died on his 22nd day in the hospital.

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'It remains a mystery as to why the index case is the sole case in which A. fumigatus was detected.'

[/module]The New England Journal also features an informative update on the meningitis outbreak, which points up an oddity of the findings thus far: That first, index case reported finding Aspergillus fumigatus in the patient, but that fungus "has not been detected in any of the subsequent 200-plus cases. The major culprit appears to be Exserohilum rostratum, a plant pathogen that rarely causes human disease. This mold has been cultured or identified by means of a polymerase-chain-reaction (PCR) assay from cerebrospinal fluid in at least 25 patients and has been detected in at least one unopened vial from the implicated lot of methylprednisolone."

The theory that E. Rostratum, a black mold, is the villain here fits with past cases:

Several outbreaks in the past decade have been associated with contamination with black molds. Exophiala species were associated with a disturbingly similar outbreak of infections including meningitis that were traced back to a contaminated lot of glucocorticoid injections from a U.S. compounding pharmacy,4 and Exophiala jeanselmei was identified in an outbreak associated with contaminated water.

In summary:

This outbreak of fungal meningitis caused by contaminated methylprednisolone used for epidural injections is evolving rapidly and now involves more than 200 patients. The primary pathogen appears to be E. rostratum, but it is possible that other pathogens could emerge, and it remains a mystery as to why the index case is the sole case in which A. fumigatus was detected. It is encouraging to note that clinically apparent disease has developed in only a small percentage of exposed patients. Management recommendations will almost assuredly change as more information becomes available regarding the pathogenesis of these infections.

This program aired on October 22, 2012. The audio for this program is not available.

Carey Goldberg Twitter Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth blog.

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