MRIs Spot 'Hidden' Fungal Infections From Tainted Steroid Shots

TUESDAY June 18, 2013 -- Armed with MRI imaging tests, Michigan doctors have detected spinal infections in patients who received tainted steroid injections for back pain but were showing no signs of illness.

The effort to identify patients with "hidden" infection was developed in the wake of last year's multi-state outbreak of fungal meningitis stemming from the contaminated steroid shots.

"The use of MRI screening detected spine and near-spine infection earlier in these patients, allowing us to provide medical and surgical care earlier," said lead researcher Dr. Anurag Malani, an infectious disease doctor at St. Joseph Mercy Hospital in Ann Arbor.

Infections showed up in 21 percent of 172 patients screened, according to the report, which was published in the June 19 issue of the Journal of the American Medical Association. Many of these people were unaware they were infected, Malani said.

The contaminated drugs, administered to alleviate back pain, sickened 745 people in 20 states and killed 58, according to the U.S. Centers for Disease Control and Prevention. Michigan was particularly hard hit, with 264 reported infections and 17 deaths.

Early in the outbreak, patients were developing meningitis and signs of stroke. Later, doctors noticed a "steady stream" of less obvious spinal or near-spinal infections surfacing months after patients received the injections.

"We need a proactive outreach to patients who have been exposed to these injections," Malani said. "If they haven't had an MRI, they need to have an MRI." This is especially true for patients experiencing worsening back pain, he said.

Because patients got the injection for constant chronic pain, they might accept new or worsening pain as part of their condition and not realize they have an infection, Malani said.

The infections -- first reported last September -- were caused by the fungus Exserohilum rostratum (basically a common black mold) found in vials of the steroid methylprednisolone, produced by the now-shuttered New England Compounding Center in Massachusetts.

The researchers identified 172 patients who had received injections at a pain center from what was later determined to be a highly contaminated drug lot. The patients had not needed any medical treatment up to that point. All underwent MRIs of the injection site, and probable or confirmed spinal or near-spinal fungal infection was subsequently diagnosed in 35 of the patients.

All the infected patients were treated with antifungal medications, and 24 patients needed surgery to clean out the infection, the researchers said.

Additionally, data on 115 of the patients indicated that 35 patients had at least one symptom, including new or worsening back or neck pain, nerve pain, or weakness in their legs.

Malani said he believes new cases of fungal infection will appear in the coming months. People who received a shot from a contaminated lot were notified at the time of the initial outbreak, and Malani recommended MRIs for those who haven't yet had medical treatment.

Roughly 14,000 people got the shots, according to the CDC, and not everyone thinks widespread MRI screening is the solution.

"We agree that patients who did not have changes in their symptoms were identified, but it would be hard to institute that process on a widespread basis," said Dr. Thomas Patterson, of the infectious diseases division at the University of Texas Health Science Center in San Antonio.

Such screening would be costly and possibly harmful to some patients, said Patterson, co-author of an accompanying journal editorial.

Another proposal -- providing antifungal therapy to everyone who received the tainted steroid -- isn't feasible either, Patterson said. "That gets into a risk-benefit sort of setting where toxicity and cost probably outweigh the benefit," he said.

He admitted, however, that symptoms can be subtle "and in some patients doing additional tests might be beneficial."

More information

For more information on fungal infections, visit the U.S. Centers for Disease Control and Prevention.

Posted: June 2013


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