Preliminary Laboratory Report of Fungal Infections Associated with Contaminated Methylprednisolone Injections

Abstract

In September 2012, the Centers for Disease Control and Prevention (CDC) initiated an outbreak investigation of fungal infections linked to injection of contaminated methylprednisolone acetate (MPA). Between 2 October 2012 and 14 February 2013, the CDC laboratory received 799 fungal isolates or human specimens, including cerebrospinal fluid (CSF), synovial fluid, and abscess tissue, from 469 case patients in 19 states. A novel broad-range PCR assay and DNA sequencing were used to evaluate these specimens. Although Aspergillus fumigatus was recovered from the index case, Exserohilum rostratum was the primary pathogen in this outbreak and was also confirmed from unopened MPA vials. Exserohilum rostratum was detected or confirmed in 191 specimens or isolates from 150 case patients, primarily from Michigan (n ‫؍‬ 67 patients), Tennessee (n ‫؍‬ 26), Virginia (n ‫؍‬ 20), and Indiana (n ‫؍‬ 16). Positive specimens from Michigan were primarily abscess tissues, while positive specimens from Tennessee, Virginia, and Indiana were primarily CSF. E. rostratum antifungal susceptibility MIC 50 and MIC 90 values were determined for voriconazole (1 and 2 g/ml, respectively), itraconazole (0.5 and 1 g/ml), posaconazole (0.5 and 1 g/ml), isavuconazole (4 and 4 g/ml), and amphotericin B (0.25 and 0.5 g/ml). Thirteen other mold species were identified among case patients, and four other fungal genera were isolated from the implicated MPA vials. The clinical significance of these other fungal species remains under investigation. The laboratory response provided significant support to case confirmation, enabled linkage between clinical isolates and injected vials of MPA, and described significant features of the fungal agents involved in this large multistate outbreak.

Utility of Real-Time PCR for Detection of Exserohilum rostratum in Body and Tissue Fluids during the Multistate Outbreak of Fungal Meningitis and Other Infections

“…First, this assay is specific to Exserohilum and cannot be used to detect other fungal DNAs. Several other fungi have been implicated in the outbreak; however, their clinical significance remains to be determined (10,14). Our results are consistent with previous observations that E. rostratum is the main etiological agent of this outbreak (10,14), as its DNA was detected in body fluids or tissues of 37% of the case patients tested.…”

“…Several other fungi have been implicated in the outbreak; however, their clinical significance remains to be determined (10,14). Our results are consistent with previous observations that E. rostratum is the main etiological agent of this outbreak (10,14), as its DNA was detected in body fluids or tissues of 37% of the case patients tested. Second, extracting fungal DNA from patient specimens remains the main challenge for this molecular detection method, since PCR assay sensitivity depends on the efficiency of DNA extraction.…”

“…By 23 October 2013 in 20 states, 752 cases were identified, resulting in 64 deaths. CDC laboratories were able to confirm fungal infections in 173 case patients (33% of the case patients from whom specimens were submitted to the CDC) by histopathology, PCR assay, or culture (3,14). In addition, with input from the Infectious Diseases Society of America and an advisory group of experts in clinical mycology, the CDC developed treatment guidelines for physicians treating patients in the outbreak (11,16).…”

“…The analytical specificity of the primers and probe used was tested with E. rostratum DNAs extracted from 21 E. rostratum isolates from case patients, 6 isolates from MPA vials, and 7 E. rostratum strains from the CDC collection. We also tested DNA extracted from 12 non-Exserohilum fungal pathogens recovered from case patients from this outbreak, such as Alternaria alternata, Aspergillus fumigatus, Aspergillus terreus, Aspergillus tubingensis, Chaetomium sp., Cladosporium cladosporioides, Cladosporium sp., Epicoccum nigrum, Paecilomyces niveus, Penicillium panem, Scopulariopsis brevicaulis, and Stachybotrys chartarum (14), as well as other clinically relevant fungi, such as Fusarium sp. and Candida albicans.…”

Development of a Multilocus Sequence Typing System for Medically Relevant Bipolaris Species

“…All isolates were maintained at 25°C. Total genomic DNA was purified using bead agitation and reagents in the DNeasy blood and tissue kit (Qiagen; Valencia, CA, USA) as previously described (20).…”