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The number of cases in the outbreak of fungal meningitis continues to rise -- reaching 185, up 15 from Thursday -- but there have been no new fatalities, the CDC said on Friday, and the first patients affected by the nationwide outbreak have begun to go home.

The first patient released – of 33 treated at Nashville's St. Thomas Hospital – is "on intravenous medication and doing very well" at home, according to Robert Latham, MD, the hospital's chief of medicine.

A second patient is ready to go home, he said, but her release has been delayed because of difficulties organizing home care for her IV medication, Latham told reporters in a conference call organized by the Tennessee department of health.

Both patients, he said, were treated early in the course of infection with intravenous antifungal agents "and they responded very quickly." He added the symptoms have almost completely resolved.

On the other hand, Latham said, the hospital has seen two of the six deaths reported in the state and has two patients that are still critically ill. The remaining 28, he added, are making progress in fighting off the infection at different rates.

Friday's Numbers Add a State

The addition on Friday of a single case in Texas brings to 12 the number of states that have now been affected, the CDC said.

Tennessee also identified another case, bringing that state's total to 50. Also included in Friday's update: Virginia and Indiana each reported three new cases, for totals of 33 and 24, respectively; Florida and Michigan reported two new cases, for totals of 9 and 41; and Maryland reported an additional new case for a total of 14.

The outbreak has been linked to three lots of a steroid, preservative-free methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass.

The drug -- mainly used to control back pain through spinal injections – is thought to have been contaminated with at least one species of fungus, whose growth led to the meningitis and other symptoms.

All three lots of the drug have been recalled, along with all other products made by the Massachusetts company.

Tennessee officials said they are now investigating whether another shipment of the drug, sent to the state in early June, was part of the three recalled lots.

As a precaution, they are contacting 111 people who were given injections from that shipment, according to state health commissioner John Dreyzehner, MD.

Dreyzehner told reporters other patients got injections from the shipment but have already been contacted because they got later shots from the recalled lots.

"As yet, we can't assure that that product was not one of the three recalled lots," he said.

All told, Dreyzehner said, health officials are monitoring about 1,200 people who got injections from one of three lots of the drug. The company shipped 2,520 vials of the compound to three Tennessee pain clinics, and all but 447 were used, officials said.

Spotting the Zebra Among the Horses

Nashville's Latham was one of the first clinicians to recognize that the outbreak was something unusual, largely because of two patients with symptoms of meningitis but blood cultures that showed no sign of bacterial infection.

That was "distinctly unusual," he said.

When colleagues at Vanderbilt University Medical Center reported they had a similar patient but had found a fungal infection, "it was obvious that something totally different was going on."

Patients who became ill have needed to be admitted to the hospital for intravenous antifungal therapy that may take several weeks, Latham said, depending on how quickly they seek treatment.

The outbreak in Tennessee has sickened about 5% of those exposed to the tainted steroid, officials said, but it's not yet clear who is most at risk or why they might be more prone to fall ill.

More than 17,000 vials of the steroid were shipped to pain clinics in 23 states.

Nationwide, state and local health officials have now contacted more than 12,000 of the estimated 14,000 people exposed to the steroid, a CDC spokesman said earlier.

Treatment Protocol Outlined

In cases of confirmed fungal meningitis, the CDC is recommending routine empiric treatment protocols to cover the possibility of bacterial infection with the addition of broad-spectrum antifungal agents.

Specifically, the agency is recommending intravenous voriconazole (VFEND), preferably at a dose of 6 mg/kg every 12 hours, combined with daily intravenous liposomal amphotericin B, preferably at a dose of 7.5 mg/kg.

The agency added that the dose of amphotericin B can be reduced to 5 mg/kg if physicians are concerned about the potential for nephrotoxicity, especially in older patients.

A liter of normal saline before the infusion is another way to minimize the risk of nephrotoxicity, the agency noted.

In cases where people have been exposed but remain without symptoms, the CDC is not recommending antifungal prophylaxis, but patients should be monitored closely for the onset of symptoms, with a low level of suspicion for a lumbar puncture to detect changes in the CSF.

The agency is also not recommending empiric antifungal treatment for patients with symptoms but normal CSF.

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