Abstract Details

Title Fatal Exserohilum Rostratum Meningitis and CNS Vasculitis after Cervical Spine Epidural Methylprednisolone Injection

Topic Infections/AIDS/Prion Disease

Presentation(s) S16 - (-)

Poster/Presentation
Number 001

Objective

Background In 2002, five reported cases[mdash]one fatal[mdash]of fungal meningitis complicating epidural steroid injection resulted from contamination with Exophiala at a compounding pharmacy. Although fulminant fungal meningitis is uncommon in immune competent patients, early recognition and treatment can be life saving.

Design/Methods Case Report.

Results A 51-year-old right-handed woman presented with occipital headaches one week after epidural steroid injection for neck pain. Unenhanced head CT was normal, and she was discharged. The following day she returned with diplopia, vertigo, nausea, and ataxia followed by step-wise cranial neuropathies, hemiplegia, and respiratory compromise requiring intubation and eventual hospital transfer. CSF showed 850 WBCs (80% neutrophils), glucose of 38 mg/dL, and total protein of 152 mg/dL. MRI revealed leptomeningeal enhancement and restricted diffusion in pons, midbrain and cerebellum. Despite broad-spectrum antimicrobials, including the late addition of an antifungal agent, the patient continued to deteriorate clinically, and death by neurological criteria was pronounced nine days after initial presentation. Cultures of both pre-mortem CSF and CSF obtained at autopsy grew Exserohilum rostratum. Autopsy revealed angioinvasive, septate fungal hyphae inducing vasculitis and hemorrhagic infarction in brain and spinal cord. Exserohilum in this patient was traced to contaminated methylprednisolone solution used in the epidural injection.

Conclusions Here we describe findings in an index case of fungal meningitis linked to a cervical epidural injection of contaminated methylprednisolone. Recognition of her symptoms as a potential complication of the procedure contributed to investigation and identification of the source of contamination, resulting in widespread product recall and close monitoring of those exposed. Broader awareness and early initiation of antifungal therapy may decrease associated morbidity and mortality, and new cases should prompt immediate investigation into potential sources of contamination to prevent further spread of disease.

Authors/Disclosures
Jennifer Lyons, MD (Brigham and Women's Hospital) PRESENTER	Dr. Lyons has received personal compensation for serving as an employee of Biogen. Dr. Lyons has received stock or an ownership interest from Biogen.
Elakkat D. Gireesh, MD, F�鶹��ýӳ�� (AdventHealth Orlando)	No disclosure on file
	No disclosure on file
Bryan Smith, MD (DC VA Neurology 3BW)	Dr. Smith has nothing to disclose.
	No disclosure on file
Deanna Saylor, MD, MHS, F�鶹��ýӳ�� (Johns Hopkins Hospital)	Dr. Saylor has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for �鶹��ýӳ��. The institution of Dr. Saylor has received research support from National Institutes of Health. The institution of Dr. Saylor has received research support from �鶹��ýӳ��. Dr. Saylor has a non-compensated relationship as a Member of multiple committees and task forces focused on improving access to MS medications to people across the world with Multiple Sclerosis International Federation that is relevant to �鶹��ýӳ�� interests or activities. Dr. Saylor has a non-compensated relationship as a Member of the Neurology and COVID19 committee with World Health Organization that is relevant to �鶹��ýӳ�� interests or activities. Dr. Saylor has a non-compensated relationship as a Member of the International Outreach Committee, Junior and Early Career Membership Committee, and �鶹��ýӳ��al Innovation Commitees with American Neurological Association that is relevant to �鶹��ýӳ�� interests or activities.
	No disclosure on file
	No disclosure on file
Tiffany Chang, MD	Dr. Chang has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for National Football League.
Laura Tochen, MD (Children's National Hospital)	No disclosure on file
	No disclosure on file
	No disclosure on file
	No disclosure on file
	No disclosure on file
John Ratchford, MD (Genentech)	Dr. Ratchford has received personal compensation for serving as an employee of Genentech. Dr. Ratchford has stock in F. Hoffman La-Roche.
Lyle Ostrow, MD, PhD (.)	The institution of Dr. Ostrow has received research support from NINDS. The institution of Dr. Ostrow has received research support from CDC National ALS Registry (ATSDR).
Robert Stevens (Johns Hopkins University)	No disclosure on file

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