By Brian Haas | The Tennessean
In just 22 days, a man in his 50s who had gotten an epidural steroid injection went from back pain and headaches to dying after being removed from life support.
The New England Journal of Medicine has published a detailed account from doctors at Vanderbilt University describing one man's rapid deterioration after receiving a tainted steroid injection for back pain from the New England Compounding Center in Framingham, Mass. The account also paints a stark picture of a particularly dangerous fungal infection that resisted treatment and can be deadly once it is introduced to the body's central nervous system.
On Saturday, the state Department of Health reported that the death toll from tainted injections in Tennessee had risen to nine, with total cases climbing from 66 to 69. Nationally, the U.S. Centers for Disease Control and Prevention reported that 284 people have been sickened and 23 have died.
Nowhere has the toll been as high as in Tennessee, where doctors first identified a fungal infection and alerted the nation to a potential outbreak. Dr. April Pettit, the Vanderbilt physician who initially realized the epidural injections could be the culprit, is the report's lead author.
"What happened here in Tennessee launched that, thanks to a handful of really great people at Vanderbilt and at the Department of Health and the Saint Thomas Outpatient Neurosurgery Center," said Woody McMillin, spokesman for the state Health Department. "And the earlier you can detect the presence of this infection in the body, the better the clinical outcome."
The doctors' account describes the man as having gotten an epidural injection of methylprednisolone for lower back pain. Four weeks later, he showed up at Vanderbilt University Medical Center with headache, neck pain, nausea, fatigue, chills and a decreased appetite. Doctors removed fluid from his spine, performed a number of tests and started treating him with antimicrobial therapy.
The man at first didn't appear to have symptoms common to meningitis, such as rashes, fever, sensitivity to light or vision changes. In fact, according to the journal, his condition improved and he was released to go home.
A week later he was back, with worsening head and back pain. He was agitated and had difficulty speaking coherently. Doctors began treating him and, again, he began to improve.
But by his sixth day at the hospital, he was sleeping, prone to staring spells, and the right side of his face began to droop. CT scans showed a mild accumulation of fluid on his brain.
On day 7, new test results changed everything.
The man's spinal fluid showed the presence of Aspergillus fumigatus, a common mold that humans and animals are continually breathing but that rarely causes problems. In certain patients with suppressed immune systems, such as leukemia patients, the fungus can be deadly.
It also can be deadly if introduced inside the spinal column.
"Aspergillosis in the central nervous system carries a poor prognosis, despite the availability of antifungal agents," Vanderbilt doctors wrote in their report.
Though this case sparked the nationwide investigation, most cases in the current fungal meningitis outbreak involve a different fungus, exserohilum rostratum, another common mold that rarely causes problems.
The aspergillus patient's condition deteriorated quickly. Four days after doctors found the fungus, he had become unresponsive, showing signs of seizure activity. They ran a tube down his throat and put him on a ventilator. Fluid continued to build on his brain.
By day 15, doctors began to notice serious brain damage in the patient. He died seven days later.
An autopsy confirmed the presence of the fungus in the man's spine, two aneurysms in his brain and brain damage throughout.
The doctors' report does not identify the patient other than to say he is a man in his 50s with a history of chronic back pain. However, earlier this month Vanderbilt confirmed that Thomas Warren Rybinski, 55, a Smyrna autoworker, died of Aspergillus meningitis on Sept. 29. As of Oct. 10, the CDC said, Aspergillus fumigatus had been identified in only one patient.
McMillin said this type of fungal meningitis is so rare that most doctors can spend their entire career without ever coming across a case. But through quick communication with state health officials, doctors at Vanderbilt raised the alarm on what turned out to be a nationwide outbreak.
"What happened here and the information that was shared will undoubtedly lead to untold numbers of lives being saved across the United States," he said.
Contact Brian Haas at 615-726-8968