Unraveling the largest outbreak of fungal infections associated with contaminated steroid injections

Findings suggest black mold targeting the base of the brain, reports The American Journal of Pathology

2013-06-26

(Press-News.org) Philadelphia, PA, June 26, 2013 – Investigators from the Centers for Disease Control and Prevention (CDC) describe pathologic findings from 40 case reports of fungal infection in patients who had been given contaminated epidural, paraspinal, or intra-articular (into joints) steroid injections and correlate these findings with clinical and laboratory data. The report, published in the September issue of The American Journal of Pathology, alerts clinicians and the general public to the catastrophic dangers of contaminated epidural injections.

In September 2012, CDC began hearing multiple reports of fungal meningitis in patients following epidural steroid injections. By June 2013, 745 people had confirmed infections and 58 had died, making this the largest reported outbreak of infections associated with epidural and intra-articular injections.

After intensive investigation, the contamination was traced to more than 17,000 vials from three contaminated lots of preservative-free methylprednisolone acetate (MPA) originating from a single compounding pharmacy. More than 13,000 people were injected with the potentially contaminated drug. Most cases were attributable to Exserohilum rostratum, a dark-colored environmental mold that rarely infects humans.

Researchers, including the CDC's Exserohilum Infections Working Group, report that of 40 cases reviewed, 16 were fatal, and all except two fatal cases had a clinical diagnosis of meningitis. Autopsy examination showed extensive hemorrhage and necrosis (tissue decay) around the base of the brain and thrombi (clots) involving the basilar arterial circulation.

Tissue specimens from infected individuals showed inflammation of the leptomeninges (thin membranes lining the brain) and blood vessel walls within the brain. Distinctive abnormalities were observed around blood vessels, and fungus was found around and within arterial walls. Interestingly, fungus deep within the brain tissue itself was found in only one case.

Similar pathologic findings were seen at the epidural injection site. Fungus was not found in tissue samples taken from the heart, lung, liver, or kidney.

Investigators wondered why fungus injected in the spinal region should target the base of the brain. "The observation of abundant fungi in the perivascular tissues, but relatively low numbers of fungi inside blood vessels, suggests migration of fungus into, rather than out of, vessels at this location. This supports the hypothesis that Exserohilum migrates from the lumbar spine to the brain through the cerebrospinal fluid with subsequent vascular invasion, rather than migration through the vasculature," suggests Jana M. Ritter, DVM, a veterinary pathologist at the CDC's Infectious Diseases Pathology Branch.

In addition to characterizing the histopathology seen in this outbreak, the authors also provide practical information for pathologists, including an evaluation of various diagnostic methods to detect the fungal infection in tissues. Polyfungal immunohistochemistry (IHC) in formalin-fixed paraffin-embedded tissues (FFPE) was found to be the most sensitive method. IHC identified fungus in 100% of cases, compared with 43% by standard hematoxylin-eosin (H&E) and 95% with Grocott's methenamine silver (GMS) stains. Factors that may affect cellular inflammatory patterns and fungal concentration are discussed, and the authors note that their findings may reflect the simultaneous introduction of the fungus along with the steroid.

INFORMATION:

Contributors to the investigation also included researchers from the Office of the Chief Medical Examiner, Louisville, KY and the Department of Pathology, University of Michigan, Ann Arbor, MI.

ELSE PRESS RELEASES FROM THIS DATE:

Asian neighborhoods: Separate but equal

2013-06-26

Asians – recently found to be the fastest growing minority group in the U.S. – have been described as the least segregated minority group in the U.S. In fact, Chinese and Indians are segregated almost as highly as Hispanics, and Vietnamese segregation is almost as high as that of African Americans. At the same time, every Asian nationality except Vietnamese lives on average in neighborhoods with higher income and share of college-educated residents than do non-Hispanic whites. This pattern is especially strong in the suburbs, according to a new study released by the ...

Tennessee grandparent's rights

2013-06-26

Tennessee grandparent's rights Article provided by Goble Law Firm Visit us at http://www.getgoble.com Of course, most grandparents want to have a close relationship with their grandchildren. As a stabilizing force in children's lives, grandparents may be especially important if the children's parents have problems. The right to a hearing for visitation Tennessee law lays out criteria that govern grandparents' rights to have access to and spend meaningful time with their grandchildren. If a custodial parent, or parents, do not allow grandparents visitation ...

Accident involving tractor-trailer shuts down highway

2013-06-26

Accident involving tractor-trailer shuts down highway Article provided by Law Offices of Kelly R. Reed, PLLC Visit us at http://www.reedkimble.com Anyone who has been involved in an accident involving a large commercial vehicle such as a tractor-trailer knows that the consequences are devastating. The chance of a serious injury or even death increases significantly in this type of accident. This is illustrated by a recent head-on collision on the West Virginia Turnpike involving a passenger vehicle and an 18-wheeler carrying hazardous materials. Three individuals ...

Proposed bill could limit athletes' workers' compensation claims

2013-06-26

Proposed bill could limit athletes' workers' compensation claims Article provided by Atcheson & Kepler Visit us at http://www.workinjury-sandiego.com The San Diego Union-Tribune recently reported on a bill that would prevent some professional athletes from filing workers' compensation claims in California. Many in opposition to the bill feel that the legislation is a way for owners of professional sports teams to avoid liability for players' injuries. Overview of the bill The bill, AB1309, seeks to prevent professional athletes who have spent a majority ...

Co-parenting after split begins during the divorce process

2013-06-26

Co-parenting after split begins during the divorce process Article provided by Zollie C. Steakley, PLLC Visit us at http://www.zolliesteakley.com Divorce can be a stressful time no matter the situation. If children are involved, however, that stress can ratchet up considerably. Co-parenting amicably -- or at least functionally -- during and after divorce can be difficult. Fortunately, there are ways to minimize conflict and raise healthy, well-adjusted children even if divorced. Begin with parenting plan The first step to co-parenting is to have a thorough ...

An increase in Florida bicycle accidents leaves some looking for answers

2013-06-26

An increase in Florida bicycle accidents leaves some looking for answers Article provided by Ingram & Eno, P.A. Visit us at http://www.ingram-eno.com/ When bicycle accidents on Clearwater's Memorial Causeway Bridge spiked, officials formed a task force to examine the bridge's structure, blueprints, accessibility, safety, traffic rates and layout looking for answers. Some preliminary findings from the task force indicate that they are having a hard time finding a definite causal link between the bridge itself and the higher accident rate. A recent Tampa Bay ...

DNA samples can be taken from arrestees, says US Supreme Court

2013-06-26

DNA samples can be taken from arrestees, says US Supreme Court Article provided by Conforti & Turner, LLP Visit us at http://www.conforti-turner.com Recently, the U.S. Supreme Court indicated a practice common among law enforcement agencies in over half the states in the country -- including California -- is legal. The high court's decision involved the issue of whether a police officer should be allowed to take a DNA sample from an individual who has been arrested, but not yet convicted of a crime. Prior to this decision, many states in the nation had already ...

US Supreme Court holds DNA samples can be taken from arrestees

2013-06-26

US Supreme Court holds DNA samples can be taken from arrestees Article provided by The Law Office of Matthew J. Davenport, P.A. Visit us at http://www.mattdavenportlaw.com The U.S. Supreme Court recently issued a decision in a case that could change certain procedures followed after an individual is arrested in North Carolina. Currently, people in North Carolina who are arrested can have their fingerprints and photograph taken. The Supreme Court's decision will also allow law enforcement officers to take a sample of the arrestee's DNA. Many people have raised ...

IRS searches for offshore bank accounts, issues penalties

2013-06-26

IRS searches for offshore bank accounts, issues penalties Article provided by Law Office of Luis R. De Luna, PLLC Visit us at http://www.delunataxlaw.com/ The Wall Street Journal recently released a report on a new tactic being implemented by the Internal Revenue Service, or IRS, to track down foreign account holders that violate the law. The tactic involves contacting a Wells Fargo & Co. bank that maintained an account for a Barbados-based bank, FirstCaribbean International Bank. FirstCaribbean used the account at Wells Fargo to wire money into other accounts ...

Studies suggest that restraining orders help curb domestic violence

2013-06-26

Studies suggest that restraining orders help curb domestic violence Article provided by Goodman & Leopold L.L.P. Visit us at http://www.goodmanleopoldlaw.com According to research from the National Violence Against Women Prevention Center, a majority of victims do not request restraining orders after the first occasion of abusive violence. Specifically, approximately 17 percent of assault victims, 36 percent of those who have been stalked and 16 percent of sexual assault victims sought orders following a first episode of abuse. Unfortunately, it can take several ...