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.
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Continuing coverage of the fungal meningitis outbreak
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.
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.
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.
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."