Compounding Pharmacies

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).

http://www.cdc.gov/HAI/outbreaks/meningitis.html

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.

Inhalation Anthrax in NYC-Fall 2001 (Part 4)

No one wanted to say it out loud. The implications were too frightening. We were pretty confident that there wasn’t a release of anthrax spores other than when media staff opened the envelopes, but that alone wasn’t going to dissolve the city’s anxiety. As the November days passed and we had no explanation for the Kathy Nguyen inhalation case we faced the inevitable. We had to eliminate one very public place as the source, we had to test the NYC subway system.

None of us believed that the NYC subway was presenting a risk to anyone. If there had been a release underground we would’ve been dealing with many inhalation cases, not one. We had a pretty good idea though that spores could be tracked from their original location and the technology to find them was sophisticated. Staff from ABC, NBC, CBS or the NY Post could’ve tracked spores on the soles of their shoes anywhere. Despite our confidence that there weren’t legions of straphangers out there incubating inhalation anthrax we worried about positive results, even a single spore. We certainly couldn’t close the subways but it would be tough public message to craft. There are anthrax spores in the NYC Subway system, but it is safe to ride. I envisioned a TV crew taping Dan Rather and the Mayor sharing a pole on a downtown 6 train to make the point.

NYPD did the sampling with CDC and us directing them. Six train lines were tested at ten stations, over 200 samples. None were positive. While we breathed a collective sigh of relief, one final, tragic case was incubating the disease. A case as mysterious as Kathy Nguyen’s but one that would finally yield some answers.