Fungal Meningitis Q&A
By Brenda Goodman, MA
WebMD Health News
Reviewed By Louise Chang, MD
Oct. 12, 2012 -- More people have been stricken with fungal meningitis that's been linked to contaminated steroid shots sold by a compounding pharmacy in Massachusetts.
So far, 184 people in 12 states have the rare meningitis, the CDC said on Friday. One person has an infected ankle after receiving one of the steroid shots. Fourteen people have died.
Health officials expect those numbers to rise.
Before the outbreak dominated news headlines, most people had never even heard of fungal meningitis.
WebMD reached out to experts in fungal diseases to get answers to common questions about fungal meningitis.
What is meningitis?
Meningitis involves swelling and irritation of the meninges, the membranes that cover the brain and spinal cord.
In most cases, these membranes become inflamed in response to a viral or bacterial infection. But certain drugs can also cause meningitis, as can cancer.
How is fungal meningitis different than the viral or bacterial types?
“First of all it's very rare, so we don't have a lot of experience with it,” says Luis Ostrosky-Zeichner, MD, an infectious disease expert and director of the laboratory of mycology research at the University of Texas Health Science Center in Houston.
In fungal meningitis, fungal organisms like mold or yeast invade the cerebral spinal fluid, the clear fluid that bathes the brain and spinal cord. They also invade the brain's blood vessels, which can cause strokes.
“With bacterial and viral meningitis, they're relatively common and physicians know how to recognize them,” says William Schaffner, MD, an infectious disease expert at Vanderbilt University in Nashville, Tenn. Schaffner has treated some of the patients involved in the outbreak.
Before the current outbreak, only doctors who treated people with very low immune systems, such as patients with HIV or those who were treated with immunity-suppressing medications, would see cases of fungal meningitis.
Is fungal meningitis contagious?
No. According to the CDC, the infection can't be passed from person to person.
What are the symptoms of fungal meningitis?
But they may be slow to develop and mild.
“The speed at which people get sick is very different,” says Benjamin Park, MD, medical officer at the Mycotic Diseases Branch of the CDC.
Unlike bacterial and viral forms of meningitis, which tend to develop within hours, fungal meningitis “creeps up on you,” Park says.
“People who have gotten infected, they've had somewhat milder symptoms than you would expect,” says Park.
Park says nearly everyone who has gotten sick has had a headache, for example, but the headache wasn't the worst-kind-you've-ever-had-in-your-life variety, as often comes with bacterial or viral meningitis.
In a few cases, Schaffner says, the first indication that anything was wrong was a stroke. “Patients can present with difficulty speaking, difficulty with their sense of balance or walking,” he says.
How long does it take to get sick?
“There's a big range,” Park says. “We've had people who've gotten sick less than a week after their injection, and we've had people that have gotten sick, the longest now is up to 42 days,” he says.
“It's important for people to stay vigilant for symptoms because we don't know enough to reassure people that they're safe,” says Park.
I've had a “meningitis” vaccine. Will that protect me?
The meningococcal vaccine protects against bacteria that cause meningitis and other meningococcal disease. It doesn't protect against fungal infection.
How is fungal meningitis diagnosed?
Doctors insert a needle into the lower part of the back to collect a fluid sample. The test is called a lumbar puncture. The fluid is sent to a lab, where technicians culture it to see if fungus will grow.
It's difficult to get fungus to grow under laboratory conditions, however, and yesterday the CDC said that some people who get meningitis will test negative for fungus.
In those cases, Schaffner says, doctors look for other signs of an infection in the spinal fluid to make the diagnosis.
“There would be an elevated number of white blood cells. The protein concentration would be high and the glucose, or sugar concentration, would be low. So that would indicate that the patient would have inflammation of those membranes surrounding the brain, and we would know that something is wrong, and we would treat the patient for meningitis,” he says.
How is fungal meningitis treated?
It's a slow process.
“[The treatments] don't kill the fungus. They just inhibit further growth. Then you have to have your immune system do the rest of the work,” Ostrosky-Zeichner says.
There are two drugs that are being used to treat infected patients: an older drug called amphotericin B and a newer drug called voriconazole.
Amphotericin B comes in several forms. One form of the drug is currently unavailable, according to a list of drug shortages kept by the American Society of Health-System Pharmacists. Other forms have been subject to shortages in the past.
Doctors say they have enough amphotericin to treat patients who need it. But they are worried they could run out if the outbreak gets worse.
“That's in the back of everyone's mind. As the case count continues to increase, more patients will need to be treated and the treatment is prolonged,” Schaffner says. “We may be talking about months for some of these patients."
What can a patient expect from recovery?
Some people will make a full recovery, but others can expect long-term damage from the infection or the drugs used to treat it.
“The recovery is long,” Schaffner says. “These fungi actually destroy tissue, and that tissue will eventually heal, but can't restore itself, so some patients will be left with disabilities.”
In addition, prolonged use of the antifungal drugs can damage the kidneys.
Strokes caused by the fungal infection may also cause lasting mental and physical problems.
“It's a calamity,” Schaffner says. “It's really terrible.”
Joint Press Briefing, CDC and FDA, Oct. 11, 2012.
Association of Health-Systems Pharmacists: "Drug Shortage List, October 12, 2012."
Luis Ostrosky-Zeichner, MD, director, laboratory of mycology research, University of Texas Health Science Center in Houston.
Benjamin Park, MD, medical officer, Mycotic Diseases Branch, CDC, Atlanta, Ga.
William Schaffner, MD, chair, department of preventive medicine, Vanderbilt University, Nashville, Tenn.
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