A medical team from Tennessee today described the diagnosis and medical care of the first patient sickened in the ongoing fungal meningitis outbreak, the case that triggered an investigation by the state's public health officials and led to the uncovering of the problem.
The patient, who died of a stroke after the fungus invaded the blood vessels in his brain, was a man in his 50s who started having headache and neck pain about 4 weeks after receiving the last in a series of epidural injections of methylprednisolone for low-back pain. Doctors from Vanderbilt University School of Medicine who were involved in the case reported their findings today in an early online article in the New England Journal of Medicine (NEJM).
Since the man's infection was identified, the number of people sickened in the multistate outbreak has climbed to 271, with 14 more cases reported since yesterday, the US Centers for Disease Control and Prevention (CDC) said today in its latest update. One more death was reported, pushing that total to 21. The number of states affected remained at 16.
The patient received a thorough work-up, including cerebrospinal fluid testing, during his first hospitalization for worsening headache and neck pain. Routine bacterial cultures were negative. The initial diagnosis was presumed community-acquired meningitis, and the patient was discharged after his condition improved with antibiotic, opiate, and nonsteroidal anti-inflammatory drug treatment.
A week later he was hospitalized again with worsening headache, back pain, and new neurologic symptoms. Over the next 2 days his symptoms improved, but by day 6 his condition started to deteriorate. His doctors began empiric treatment with liposomal amphotericin B, and the following day the hospital's lab found Aspergillus fumigatus in the cerebrospinal fluid sample collected the first day of the man's hospitalization.
The physicians added intravenous voriconazole to his treatment regimen and started looking for clues to the fungal source of the infection, but a computed tomography (CT) scan of the chest showed no sign of fungal infection. Magnetic resonance imaging (MRI) of the brain showed midbrain and cerebellar infarcts, but an exam of the paranasal sinuses revealed nothing unusual.
On the eleventh day of hospitalization the man became unresponsive and had seizure symptoms. Cerebral imaging studies suggested an intraventricular hemorrhage with evidence of a mycotic aneurysm. Though cerebrospinal test findings and seizure activity improved, his doctors saw no neurologic recovery. He died 11 days later, after MRI showed new infarcts and the family decided not to pursue aggressive therapy, given the severity of the patient's injuries.