The official case count is up to 105 in the largest outbreak
of fungal meningitis in US history, but it will undoubtedly go higher as more
cases are recognized as being connected to the contaminated medicine (CDC
currently is updating the case counts once a day).
Fungal meningitis is the rarest form of meningitis and it is
not contagious from one person to another. It usually occurs only in people who
have a damaged immune system, like those with AIDS or undergoing chemotherapy. I
heard a TV interview by a doctor, not a public health official, but an
infectious disease specialist. He said we’ve never seen anything like this
before. Well, he’s not exactly correct. A few years back there was an outbreak of
Pseudomonas fluorescens traced to a
compounding pharmacy in Texas. It involved kids with serious diseases, like
cancer, who had indwelling catheters that required periodic flushing wit a
heparin preparation to keep them from clogging. See http://cid.oxfordjournals.org/content/47/11/1372.full.pdf
What are compounding pharmacies? They are a lot like the big
factories that produce food for retail stores. They buy large quantities of medication, like steroids, then
mix them with sterile water or another solution and prepare vials for doctors.
They exist because they can produce the drug at a cheaper price than pharmacies
with more rigorously oversight. The problem is that organisms, mostly bacteria
and fungi, have a way of getting everywhere. Unless you use high tech systems
to ensure absolute sterility mistakes like this can happen. Just like one
contaminated cow can be spread E. coli
to a lot of ground beef one unsterile step in a compounding pharmacy can
contaminate a lot of medicine.
What is odd and concerning is that the injections of steroids
into the spinal column is resulting in meningitis. The goal of the procedure is
to inject the medicine around the nerve root as it emerges from the spinal
cord. Decreasing inflammation by
the use of steroids will reduce pain. Most of the time the placement of the
needle is checked with fluoroscopy and dye. The spinal sac is not penetrated,
which means that the infections in the outbreak are a result of direct fungal invasion
though the spinal cord membrane or via the bloodstream. Both scary situations.
