Perhaps more details than the original article. This is from a medical publication.
Suspected Fungal Meningitis Outbreak Associated With Procedures Performed Under Epidural Anesthesia
The CDC is looking for almost 200 U.S. patients who might be at risk for meningitis after receiving surgeries at the River Side Surgical Center or Clinica K-3, in Matamoros, Tamaulipas, Mexico. The surgeries took place between Jan. 1 and May 13.
Both ambulatory surgery centers were closed on May 13 after an outbreak of suspected fungal meningitis occurred among four patients in Mexico, who had surgical procedures at the clinics that involved epidural anesthesia.
The CDC and the Mexican Ministry of Health are investigating the cause of the outbreak, and the CDC is working with 24 U.S. state and local health departments to trace the Americans who might be at risk.
The CDC advised at-risk patients to seek urgent medical care immediately—even if they do not have symptoms—for diagnostic testing for fungal meningitis, which includes MRI scanning and a lumbar puncture.
Public health officials have not yet determined the cause the outbreak, but a fungal infection is suspected based on elevated cerebrospinal fluid and serum levels of the fungal biomarker (1,3)-beta-D-glucan in several patients. The spinal taps of the four Mexican patients tested positive for Fusarium solani.
“Per the CDC announcement, the investigation of the current outbreak is presently ongoing but isolation of Fusarium solani has been identified in some cases. CDC and partners are investigating to determine how people were exposed to the infectious organisms during the procedures, and their source,” said Thomas M. File Jr., MD, MSc, MACP, FIDSA, FCCP, the chair of the Infectious Disease Division and the co-director of the antimicrobial stewardship program at Summa Health, in Akron, Ohio. Dr. File is not involved in the outbreak investigation but was asked to comment.
“My initial thought regarding this outbreak is to remember the multistate fungal meningitis outbreak in the U.S. back in 2012, during which 753 patients were infected leading to 64 deaths. This outbreak was traced to contaminated methylprednisolone used in epidural injections and which were prepared by a compounding pharmacy,” Dr. File said.
Philip S. Barie, MD, a professor emeritus of surgery at Weill Cornell Medical College, said he was reminded of a bacterial outbreak about 10 years ago in an ambulatory surgery center in the Midwest that was related to a contaminated single-use vial of propofol used for multiple procedures.
“That's a leading suspicion here, although we're dealing with a fungal infection, not a bacterial infection,” Dr. Barie said. “The reason why I am suspicious of that [contamination of a vial] is because recently in the state next door in Mexico, Durango, there was an episode of infections related to multiple uses of single-use bupivacaine also in an ambulatory setting, and bupivacaine is, of course, a workhorse local anesthetic that’s used,” he told Infectious Disease Special Edition.
Trying to find the source is important and might take some time, according to Dr. Barie, who is also not involved in the investigation. There are several possibilities, according to both physicians: a break in sterile practices either in infection control or cleaning; contamination of the medication itself by the clinic staff; or contamination that occurred during manufacturing.
“It’s bad manufacturing practices, bad clinical practices or bad infection control practices. They're basically the three things that need to be elucidated here,” said Dr. Barie, who is also the executive director of the Surgical Infection Society Foundation for Research and Education.
“This certainly signals a need to be aware of anyone who had spinal injections at the specified clinics in Matamoros, Mexico, and is an illustration of the potential risks of medical tourism,” said Dr. File, who is also a member of the Infectious Disease Special Edition editorial advisory board.
Although this area in Mexico is popular for medical tourism, both physicians warned against the practice.
“While there may be advantages of significant reduced costs when seeking care outside the U.S., patients need to be aware of potential consequences of harm. Currently the CDC is advising all members of the public to cancel any elective procedures that involve an epidural injection in Matamoros, Mexico, until there is evidence that there is no longer a risk at these clinics,” said Dr. File, who is also a professor of internal medicine and the chair of the Infectious Disease Section at Northeast Ohio Medical University, in Rootstown.
“As [doctors] in the U.S., we never, ever, recommend that people should go out of the country for medical care. My personal advice would be, ‘Don't do it. The risks are high,’” Dr. Barie added.
The CDC recommended that medical tourists cancel any elective procedure that involves an epidural injection of an anesthetic in Matamoros—and any travel associated with such a procedure—until there is no longer a risk for infection.
Ongoing Investigation
The agencies are investigating to determine how people were exposed to the organism during the procedures, as well as whether any other clinics are involved.
The Mexican Ministry of Health shared a list of 221 U.S. patients who might be at risk for meningitis based on their recorded surgical procedures at either clinic, but the agency was able to eliminate six because they did not receive epidural anesthesia. However, public health officials also identified five additional patients with potential exposure who were not on the original list. With these findings, an overall total of 220 people in the United States are known to have potential exposure.
Of the U.S. cases so far, 14 people have symptoms consistent with meningitis, but spinal tap results are pending or unknown; 11 people are probable cases whose spinal tap results suggest meningitis, but a fungus was not isolated. No cases have been confirmed and there have been two deaths, which the CDC has called “probable” cases.
Symptoms of fungal meningitis include fever, headache, stiff neck, nausea, vomiting, sensitivity to light, and confusion. It can take weeks for symptoms to develop, and they may be very mild or absent at first. However, once symptoms start, they can quickly become severe and life-threatening. Early testing and diagnosis greatly improve outcomes, according to the CDC.
Interim recommendations for diagnosis and management of cases of suspected fungal meningitis associated with epidural anesthesia administered in Matamoros, Mexico, are available here.
