Tom Wilemon The Tennessean
When moldy medicine is injected into people's spinal columns, spawning incredibly rare forms of fungal meningitis, doctors have few treatment options and don't know how to keep people from getting sick.
The
toll continued to rise Wednesday with 137 cases reported nationwide,
including 12 deaths, according to the U.S. Centers for Disease Control
and Prevention. Tennessee had 44 of those cases with six deaths.
The
CDC also warned that people who got injections of the recalled lots of
steroid medicine, methylprednisolone acetate, in their knees and other
joints could develop septic arthritis.
At the epicenter of the
outbreak, infectious disease specialist Dr. Robert Latham is doing what
he can for the 25 patients with fungal meningitis at Saint Thomas
Hospital.
His options are limited.
The two antifungal
medicines in his arsenal -- voriconazole and amphotericin B -- have such
vicious side effects that one carries the nickname "ampho-terrible."
The drugs fight the fungus but can damage the liver and kidneys. They
shouldn't be given, the CDC says, unless a patient's spinal fluid is
clouded by infection.
Patients ill enough to receive the drugs can expect to be tethered to an intravenous drip for months.
Medical research provides little guidance for doctors, and scant case history to predict the outcome.
"I
don't think anybody in the country or the world, except for some very
rare exceptions, has seen anything like this -- certainly not at the
volume we're seeing now," Latham said.
But the drugs are showing results, said Latham.
"I can tell you with the people we've been treating the longest, we're seeing improvement in their spinal fluid," he said.
Potentially hazardous
Dozens
more people sick with worry come to the hospital wondering if the
soreness in their necks is from tension or a first symptom of fungal
meningitis -- something they may have contracted through tainted epidural spinal injections at the Saint Thomas Outpatient Neurosurgery Center on the hospital's ninth floor.
Desperate to keep from getting ill, the patients from there and two other Tennessee pain clinics ask for preventive medicine.
"Do
they not have something if this was to occur?" said Lourdes Gonzalez,
who got her injections of the potentially contaminated steroid at the
Specialty Surgery Center in Crossville.
But health officials say they know of nothing that can protect those exposed to the recalled drugs.
For
people who show symptoms of the disease, a doctor will perform a spinal
tap so the fluid can be tested for fungi linked to the outbreak. If the
test turns out negative, the patient is sent home -- but without a
clear bill of health. The pathogens can hide inside the spinal canal and
not show up initially.
The CDC currently does not recommend
prescribing the antifungals as a preventive measure. Some of the
nation's top infectious disease experts have talked about the pros and
cons of such an action, but they can only guess whether a pre-emptive
strike would work.
"We would be going to Mars, in effect," said
Dr. William Schaffner, a Vanderbilt professor who is president of the
National Foundation for Infectious Disease.
Using the medicine in
such a way could be potentially hazardous to patients, who may have
gotten injections from a fungus-free vial, Schaffner said. And he said
there's no proof that the treatment would keep people from getting sick.
'Attack rate'
Most
people exposed to the possibly tainted drugs will not get fungal
meningitis, health officials say -- although some may have better
chances than others, depending on which lot of recalled medicine was
used for their injections.
Three lots of methylprednisolone
acetate were recalled, but one has shown a higher "attack rate" than the
other two, said Dr. David Reagan, chief medical officer for the
Tennessee Department of Health. The lot number with the highest number
of cases is #06292012@26, BUD 12/26/2012.
Even for those receiving
shots from that lot of medicine, the chance of illness is relatively
small, Reagan said. "Currently, it changes, but it is a bit less than 5
percent of the people that have been exposed.
"Some lots have substantially less percentage than that."
Saint
Thomas Outpatient Neurosurgery Center received medicine from all three
recalled lots, but patients who have called the clinic or the hospital
to ask which lot numbers their injections came from have not gotten
answers. Tennessee does not require clinics to track the lot numbers on
individual patient records for the steroid injections. However, health
officials do have records of which lots went to the 75 clinics
nationwide -- information they can use as a baseline to assess the
attack rates.
Symptoms of meningitis include stiff neck, worsening headache or fever.
Infection
of an arthritic joint, such as a knee, may be occurring if someone who
got an injection suffers new or worsening pain with swelling, increasing
pain, redness and warmth at the injection site, according to the CDC.
New territory
Scientists
and doctors are learning more about the outbreak day-by-day. At first,
only one type of fungus, Aspergillus, was thought to have contaminated
the steroid medicine. Over the weekend, the CDC said it had found a second fungus.
On Tuesday, the Tennessee Department of Health announced that the
majority of the cases in this state were actually from Exserohilum, the
second type of fungus.
Tennessee Health Commissioner Dr. John
Dreyzehner characterized this form of fungal meningitis as "an
exceptionally rare disease."
Cases so far indicate that the
antifungal medicines help people who are diagnosed and treated early,
Dreyzehner said. "There is a balance here, though, because they are
potentially very toxic medications."
The CDC is also advising
doctors to prescribe antibacterials because they are not yet sure what
contaminants may have been in the recalled medicine.
At Saint
Thomas, fungal meningitis patients run the gamut from stable condition
-- able to walk the halls -- to critically ill. The majority of patients
are stable, the hospital said.
Latham and other doctors are
looking to the CDC for better guidance on the use of the antifungals,
particularly among older people with reduced kidney function, Dreyzehner
said.
Experts are sharing their knowledge in conference calls.
And the CDC has a team of scientists gathering outcome data, researching
the scant accounts in medical literature about these rare illnesses and
comparing notes on the best ways to use the medicine.
Said Schaffner: "Let's remember that we're in new territory."