Meningitis Cases Are Linked to Steroid Injections in Spine

By DENISE GRADY, from The New York Times

Dr. April Pettit,  an infectious diseases specialist at Vanderbilt University, was worried about her patient. He had been ill with meningitis for two weeks, he was not getting better, and she could not figure out why. Antibiotics, the usual treatment, were not helping. Bacteria, the usual suspects, could not be found.

On the morning of Sept. 18, as she and a colleague were examining the patient and talking to his family, a pager buzzed. It was the hospital lab, with an answer at last — but a troubling one.

ny times

A culture of the patient’s spinal fluid had revealed a fungus, Aspergillus. The patient was so ill that he could no longer communicate, so Dr. Pettit spoke to the family.

“I told them it was a very unusual cause of meningitis in healthy people, and that we needed to try to figure out how he got this infection,” she said.

Had he done anything unusual in the weeks before he became ill? she asked.

The answer alarmed her. He had had a steroid injection in his spinal area to relieve back pain — a common treatment, administered to millions of people in the United States every year.

Dr. Pettit called the State Health Department.

She is now credited with being the clinician who recognized the “index case” in what has become a frightening outbreak of meningitis that has killed two people and sickened 12 others who also received steroid injections in their spines for pain. Doctors suspect that the steroid medicine was contaminated with the fungus. The meningitis does not spread from person to person.

Officials said it was not possible to predict the extent of the outbreak yet. Thirteen of the patients have been in Tennessee, and one in North Carolina. Two of the cases were new as of Tuesday, and health officials have said that there could be more cases and that other states could be affected.

“I don’t think we’ve identified all the cases that will be identified,” said Dr. David Reagan, the chief medical officer for the Tennessee Health Department.

Dr. Pettit’s patient was one of the two who died.

The Tennessee patients were treated at the Saint Thomas Outpatient Neurosurgery Center in Nashville, which was closed on Sept. 20. Center staff members notified more than 700 patients who received injections of the suspect drug. Another Tennessee clinic, the Specialty Surgery Center in Crossville, also received shipments of the possibly contaminated drug and was notifying patients.

Health officials emphasized that the problem appeared to come from the medication and not the clinics themselves, and that the clinics had immediately cooperated by notifying patients and, in the case of Saint Thomas, shutting down when the outbreak was recognized. But the officials have released few details about the source of the drug, saying the investigation was continuing.

All the patients who became ill were treated with one or more injections between July 30 and Sept. 18, and the incubation period — the time between exposure and when the patient gets sick — has ranged from seven days to about four weeks. That means that some patients may become ill in the next few weeks. Symptoms can include headache, dizziness, fever, loss of balance and slurred speech.

At a news conference on Tuesday, state health officials said some of the patients were recovering, but some were in critical condition.

The outbreak has led to a nationwide recall of the drug that all the patients received. The drug, preservative-free methylprednisolone acetate, was prepared by one compounding pharmacy, a pharmacy that prepares drug mixtures or solutions for hospitals and clinics. Health officials have declined to name the pharmacy or release lot numbers of the drug, but a spokesman for the Centers for Disease Control and Prevention said that all of the suspect lots had been recalled and that the pharmacy had stopped producing the medication.

Scientists are also testing other medications used in giving the spinal injections, like numbing agents and antiseptic wipes. They say the cause has not been determined for sure.

The treatments are called lumbar epidural steroid injections, but they are not the same as the epidurals commonly given to women for childbirth or Caesarean sections — something that health officials wanted to make clear to avoid creating alarm among women who have recently given birth.

Dr. William Schaffner, the chairman of preventive medicine at Vanderbilt, said that this type of fungal meningitis was serious and difficult to treat, and that the C.D.C. had convened an expert panel to help determine the best treatment. The disease can also be difficult to diagnose, because unlike other types of meningitis, it can cause strokes, and when a patient has stroke symptoms, doctors may not look for an infection as well. In addition, the organism can be difficult to grow in cultures of spinal fluid from patients, making the diagnosis even more of a challenge.

Detecting and treating the disease as early as possible gives the best chance of curing it, Dr. Schaffner said, so getting the word out to alert both doctors and patients to the symptoms is important.

He said that he understood the investigators’ reluctance to name the drug maker or provide full details until the investigation is finished, but that the outbreak and its link to the steroid medication have caused quite a bit of worry among both doctors and patients about whether other steroid preparations are safe.

“We have had many concerns expressed in our own institution,” he said. “Providers say, ‘Can we continue to use the steroids sent to us by our own pharmacy?’ ”

meningitis outbreak

Others doctors also wanted more information. Dr. Christopher Standaert, a specialist in spinal and neuromusculoskeletal care at the University of Washington in Seattle, and a spokesman for the North American Spine Society, said he hoped that health officials would release the name of the product, the manufacturer and the lot numbers thought to be involved in the outbreak so that clinics could make sure it was not on their shelves.

“That would help the spine community,” he said. “The rest of us would like to know. It would be nice if they told the hospitals.”

Dr. Pinna says:

The term “Steroid”  is what most people call “Cortisone.” It is very common for doctors in the USA and Europe to inject “steroids” into muscles that are painful—especially in the low back near the spine.

The usual comment from the doctor is:  “This may help you—but, if it doesn’t, it wont do any harm…”

We are seeing in this article that steroid injects can do a lot of harm.

Steroids (or “cortisone”) reduces the effects of the Immune System. The Immune System produces Inflammation which in turn produces swelling and pain.  Your doctor is hoping that by reducing the inflammation he will reduce the pain.

Now, as we see in this article, some of the injections may introduce a fungus into the spine.  This should not happen if the needle was only in the muscle. However, some doctors inject directly into the spinal canal in order to relieve inflammation in the nerve roots.

We have to realize that this is an uncommon result caused by a contaminated batch of steroids.

However, Contamination  itself is becoming more common as the health industry grows larger and larger

Of interest to note, statistically, only fifty percent of spinal injections are successful!

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Comments (2)

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  1. I just saw on CNN that there is a meningitis outbreak, glad Texas colleges required us to get that shot now

    • Kevin,

      Oxytocin levels are rarely obtained. Generally only
      during obstetric procedures.

      Here is an abstract from a study:

      Plasma Hormone Levels
      The blood samples were collected in ice-chilled tubes. After centrifugation,
      the plasma was removed and the samples were stored
      at 801C until analysis. Plasma concentrations of cortisol and
      adrenocorticotropic hormone (ACTH) were determined using an
      in-house radio immunoassay (Pratt, 1978). These analyses were
      performed at the University Medical Center of Groningen. Before
      oxytocin was analyzed, plasma was extracted with acetone
      (Guarantee Reagent [GR]; Merck, Darmstadt, Germany) and
      petroleum benzene (GR; boiling point range 401–601C; Merck)
      with a recovery of 92%. Oxytocin levels were measured by radioimmunoassay
      at the Swedish University of Agricultural Sciences
      in Uppsala, Sweden, at the Department of Animal
      Physiology. The antibody KA19 was used for the analysis
      (Milab, Sweden). The limit of detection was 4.68 pmol/l and
      interassay coefficients of variationwere low, 22.06%, CV59.57,
      medium, 37.83%, CV58.81, high, 529.8%, CV56.81; intrassay
      %CVo10 conc.520.90–1026 (Stock & Uvna¨s-Moberg,

      Dr. Pinna

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