By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: An outbreak in Mexico of meningitis due to Fusarium solani has affected at least 79 patients who had received epidural injections; at least 35 (44.3%) have died.
SOURCE: Promed Mail. Fungal meningitis — Mexico: (DU) fatal, contaminated epidural anesthetic susp. Archive number: 20230208.8708225. Feb. 7, 2023. https://promedmail.org/promed-...
The Pan American Health Organization (PAHO) received a report of an unusual outbreak of meningitis from Mexican health authorities on Nov. 4, 2022. This involved a cluster of 11 cases of “aseptic” meningitis of unknown etiology in individuals who each had undergone procedures that involved the administration of epidural anesthesia. The procedures had been performed in private hospitals in Durango, Mexico. One of the 11 patients had died.
Approximately two weeks later, Durango authorities reported that the infections were caused by Fusarium solani, although reports indicated it had not been detected in samples of local anesthetic that had been injected into the epidural space.
By Dec. 26, 2022, Fusarium solani meningitis had been identified in 74 women and three men, each of whom had received epidural anesthesia in association with surgical procedures at one of the four hospitals. Twenty-nine (37.7%) of the 77 patients had died by then. By Feb. 6, 2023, the total number of cases and deaths had reached 79 and 35 (44.3%), respectively.
COMMENTARY
History repeats itself (or, as has been said, at least it rhymes). In 2012, an outbreak in the United States of meningitis caused by contamination of methylprednisolone used for epidural injections with Exserohilum rostratum affected at least 749 patients, 61 (8%) of whom died.1 The methylprednisolone had been contaminated at a single compounding pharmacy with national distribution.
The plant pathogen Fusarium is an ascomycete that may cause both superficial and invasive disease in humans, with the latter predominantly occurring in the immunocompromised. Fusarium solani is one of 600 species and causes one-half of infections caused by this genus. It frequently is resistant to several antifungal agents, and treatment of invasive infections is poorly understood.
Amphotericin B, voriconazole, and even terbinafine, often in varying combinations, have been used. Optimal treatment of Fusarium meningitis is unknown. Although voriconazole has been effective in central nervous system infections caused by other fungi, amphotericin might require intrathecal administration. To my knowledge, penetration of terbinafine into cerebrospinal fluid has not been reported, and it had minimal effect in a rabbit model of coccidioidal meningitis.2
REFERENCES
- Smith RM, Schaefer MK, Kainer MA, et al; Multistate Fungal Infection Outbreak Response Team. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med 2013;369:1598-1609.
- Sorensen KN, Sobel RA, Clemons KV, et al. Comparative efficacies of terbinafine and fluconazole in treatment of experimental coccidioidal meningitis in a rabbit model. Antimicrob Agents Chemother 2000;44:3087-3091.
