neurologic disorders
Subacute and Chronic Meningitis
Fungal meningitis that develops after epidural methylprednisolone injection
Occasionally, outbreaks of fungal meningitis have occurred in patients given spinal epidural injections ofmethylprednisolone. In each case, the drug had been prepared by a compounding pharmacy, and there were significant violations of sterile technique during drug preparation. The first outbreak in the US (in 2002) resulted in 5 cases of meningitis. The most recent outbreak (in late 2012 and 2013) resulted in 753 cases of meningitis, stroke, myelitis, or other fungal infection-related complications and in 61 deaths. Outbreaks have also occurred in Sri Lanka (7 cases) and Minnesota (1 case). Most cases were caused byExophiala dermatitidisin 2002 and byExserohilum rostratumin 2012 and 2013; a few cases were caused byAspergillusorCladosporiumspecies. The meningitis tends to develop insidiously, often with infection at the base of the brain; blood vessels may be affected, resulting in Overview of Vasculitis and Typical CSF findings include Neutrophilic pleocytosis Elevated protein Frequently low glucose The most sensitive test forExserohilummeningitis is a polymerase chain reaction (PCR) test, available through the Centers for Disease Control and Prevention (CDC); in a few cases, the diagnosis can be based on culture. Aspergillusmeningitis may be suspected if galactomannan levels in CSF are elevated; diagnosis is based on culture. Meningitis due toExophialaorExserohilumspecies is rare, and definitive treatment is not known. However,voriconazole6 mg/kg/day IV is recommended initially. Drug dosage should be adjusted based on blood levels of the drug. Liver enzyme and sodium levels should be measured periodically during the 2 to 3 weeks after initiation of treatment. Prognosis is guarded, and appropriate treatment does not guarantee survival. 