Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report

BMC Research Notes

David Sullivan¹  Kristine Johnson⁴  Rafael Llinas³  Susan Rhee⁴  Lucy Wilson²  Jee Bang³  Elizabeth Felton³  Kiran Thakur³  Olga Fermo³  George Nelson⁴ 

[1] W. Harry Feinstone Department of Microbiology and Immunology, Room E5628, The Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St, Baltimore, Maryland 21205, USA;Maryland Department of Health and Mental Hygiene, Baltimore, Maryland, USA;Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

关键词: Voriconazole;    Infected aneurysm;    Mycoses;    (1,3) beta-D-glucan;    Fungal polysaccharides;   

Others  :  1132654
DOI  :  10.1186/1756-0500-7-327

 received in 2013-12-09, accepted in 2014-05-28,  发布年份 2014

【 摘 要 】

Background

In the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality.

Case presentation

We report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment.

Conclusions

This is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.

【 授权许可】

   
2014 Nelson et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Engemann J, Kaye K, Cox G, Perfect J, Schell W, McGarry SA, Patterson K, Edupuganti S, Cook P, Rutala WA, Weber DJ, Hoffmann KK, Engel J, Young S, Durant E, McKinnon K, Cobb N, Bell L, Gibson J, Jernigan D, Arduino M, Fridkin S, Archibald L, Sehulster L, Morgan J, Hajjeh R, Brandt M, Warnoch D, Duffus WA: Exophiala infection from contaminated injectable steroids prepared by a compounding pharmacy--United States, July-November 2002. MMWR Morb Mortal Wkly Rep 2002, 51(49):1109-1112.
• [2]Pettit AC, Kropski JA, Castilho JL, Schmitz JE, Rauch CA, Mobley BC, Wang XJ, Spires SS, Pugh ME: The index case for the fungal meningitis outbreak in the United States. N Engl J Med 2012, 367(22):2119-2125.
• [3]Kuehn BM: CDC probes new outbreak associated with compounded steroids. Jama 2013, 309(24):2541.
• [4]Multistate Fungal Meningitis Outbreak Investigation [http://www.cdc.gov/HAI/outbreaks/meningitis.html webcite]
• [5]Kauffman CA, Pappas PG, Patterson TF: Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med 2013, 368(26):2495-2500.
• [6]Bell WR, Dalton JB, McCall CM, Karram S, Pearce DT, Memon W, Lee R, Carroll KC, Lyons JL, Gireesh ED, Trivedi JB, Cettomai D, Smith BR, Chang T, Tochen L, Ratchford JN, Harrison DM, Ostrow LW, Stevens RD, Chen L, Zhang SX: Iatrogenic Exserohilum infection of the central nervous system: mycological identification and histopathological findings. Mod Pathol 2013, 26(2):166-170.
• [7]Gade L, Scheel CM, Pham CD, Lindsley MD, Iqbal N, Cleveland AA, Whitney AM, Lockhart SR, Brandt ME, Litvintseva AP: Detection of fungal DNA in human body fluids and tissues during a multistate outbreak of fungal meningitis and other infections. Eukaryot Cell 2013, 12(5):677-683.
• [8]Brandt ME, Warnock DW: Epidemiology, clinical manifestations, and therapy of infections caused by dematiaceous fungi. J Chemother 2003, 15(Suppl 2):36-47.
• [9]Filizzola MJ, Martinez F, Rauf SJ: Phaeohyphomycosis of the central nervous system in immunocompetent hosts: report of a case and review of the literature. Int J Infect Dis 2003, 7(4):282-286.
• [10]Multistate outbreak of fungal meningitis and other infections [http://www.fda.gov/Drugs/DrugSafety/FungalMeningitis/default.htm webcite]
• [11]Lyons JL, Roos KL, Marr KA, Neumann H, Trivedi JB, Kimbrough DJ, Steiner L, Thakur KT, Harrison DM, Zhang SX: Cerebrospinal fluid (1,3)-beta-D-glucan detection as an aid for diagnosis of iatrogenic fungal meningitis. J Clin Microbiol 2013, 51(4):1285-1287.
• [12]Mikulska M, Furfaro E, Del Bono V, Raiola AM, Di Grazia C, Bacigalupo A, Viscoli C: (1–3)-beta-D-glucan in cerebrospinal fluid is useful for the diagnosis of central nervous system fungal infections. Clin Infect Dis 2013, 56(10):1511-1512.
• [13]Kannoth S, Iyer R, Thomas SV, Furtado SV, Rajesh BJ, Kesavadas C, Radhakrishnan VV, Sarma PS: Intracranial infectious aneurysm: presentation, management and outcome. J Neurol Sci 2007, 256(1–2):3-9.
• [14]Kleinfeld K, Jones P, Riebau D, Beck A, Paueksakon P, Abel T, Claassen DO: Vascular complications of fungal meningitis attributed to injections of contaminated methylprednisolone acetate. JAMA Neurol 2013, 70(9):1173-1176.
• [15]Theuretzbacher U, Ihle F, Derendorf H: Pharmacokinetic/pharmacodynamic profile of voriconazole. Clin Pharmacokinet 2006, 45(7):649-663.