The Centers for Disease Control and Prevention (CDC), in collaboration with state and local health departments and the Food and Drug Administration (FDA) , is investigating a multistate outbreak of fungal meningitis and other infections among patients who received contaminated preservative-free MPA steroid injections from New England Compounding Center (NECC). Several patients suffered strokes that are believed to have resulted from their infections. The investigation also includes other infections from injections in a peripheral joint, such as a knee, shoulder, or ankle. Patients who received injections in peripheral joints only are not believed to be at risk for meningitis, but they could be at risk for joint and other infections.

CDC and public health officials are referring any patients who have symptoms that suggest possible infections to their physicians for further evaluation.

• The predominant fungus identified in patients and confirmed in the CDC laboratory continues to be Exserohilum rostratum. One patient, the index case, had a laboratory-confirmed Aspergillus fumigatus infection. These fungi are common in the environment; fungal infections are not transmitted from person to person. For up-to-date laboratory results, see the Multistate Fungal Meningitis Outbreak Laboratory Testing and Results site.
• CDC and FDA have confirmed the presence of a fungus known as Exserohilum rostratum [JPG - 183 KB] in unopened medication vials of preservative-free MPA from two of the three implicated lots (Lot #06292012@26, BUD12/26/2012 and Lot #08102012@51, BUD 2/6/2013). The laboratory confirmation further links steroid injections from these lots from NECC to the outbreak. Testing on the third implicated lot continues.
• Patients and clinicians need to remain vigilant for onset of symptoms because fungal infections can be slow to develop. In this outbreak, symptoms typically have appeared 1 to 4 weeks following injection, but it’s important to know that longer and shorter periods between injection and onset of symptoms have been reported. Therefore, patients and physicians need to closely watch for symptoms for at least several months following the injection. See updated Patient Guidance for more information, and contact your physician if you are concerned you may have become ill from your injection.
• CDC has recently become aware of reports of spinal epidural abscess and arachnoiditis among a number of patients undergoing treatment for fungal meningitis associated with the outbreak. Both conditions are rare but serious disorders in the general population that require prompt medical attention. Most of these early reports have been about patients in Michigan and Tennessee, but other states have reported patients with these conditions as well. Additional information is found in the Clinician FAQ’s. CDC is working with clinicians and public health officials to obtain more information and refine its clinical guidance as needed.

Clinicians should continue to closely monitor patients who have received medicines associated with the following three lots of preservative-free methylprednisolone acetate (80mg/ml) from the New England Compounding Center (NECC) that were recalled on September 26, 2012.

• 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 potentially contaminated injections were given starting May 21, 2012. See the Clinician Guidance webpage for more information.

CDC's guidance to patients has not changed as a result of the expanded voluntary recall of all NECC products, announced on October 6, 2012.

Patients who believe they might have received a potentially contaminated medication should contact the physician who performed their procedure to find out if their medication was from one of the three lots.

Patients who received a potentially contaminated medication should seek medical attention if they have any symptoms.

Patients need to remain vigilant for onset of symptoms because fungal infections can be slow to develop. Typically in this outbreak, symptoms have appeared 1 to 4 weeks following injection, but it’s important to know that longer and shorter periods of time between injection and onset of symptoms have been reported. Therefore, patients and physicians need to closely watch for symptoms for at least several months following the injection. For more information, see updated Patient Guidance.

Selected Quotes

“We are working tirelessly with our state public health partners to track down patients who may have received these medications. If patients are identified soon and put on appropriate antifungal therapy, lives may be saved.” -Benjamin J. Park, MD, State Response and Surveillance Team Lead for the Multistate Fungal Meningitis Outbreak and Chief Epidemiologist with the Mycotic Diseases Branch, US Centers for Disease Control and Prevention

“Given that fungal infections of this kind have never been seen before, the doctors caring for these patients are going to need guidance. CDC has convened the nation’s top clinical fungal experts to work with us in developing diagnostic and treatment guidance for physicians caring for these patients. Patients who are concerned about whether they were exposed to a potentially contaminated product should contact the physician who performed their injection.” -John Jernigan, MD, MS, Clinical Team Lead of the Multistate Fungal Meningitis Outbreak and Director of the Office of Health Associated Infections Prevention Research and Evaluation, Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention

“Patients deserve to be safe wherever they receive their medical care. This tragic outbreak highlights the need to ensure that all products, materials, and procedures used in healthcare are safe.” -J. Todd Weber, MD, Incident Manager of the Multistate Fungal Meningitis Outbreak and Chief of the Prevention and Response Branch of the Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention

CDC works 24/7 saving lives and protecting people from health threats to have a more secure nation. Whether these threats are chronic or acute, manmade or natural, human error or deliberate attack, global or domestic, CDC is the U.S. health protection agency.