In a new perspective piece being published Online First tonight in Annals of Internal Medicine, a physician recalls lessons learned from treating patients affected by the 2002 outbreak of Exophiala (Wangiella) dermatitidis meningitis or arthritis related to contaminated, injectable corticosteroids prepared from a compounding pharmacy.
According to the author, the lessons he learned in 2002 are applicable to the current outbreak. He warns that compounding of preservative-free corticosteroids requires meticulous sterility to ensure lack of fungal contamination. Without this sterility, fungus grows aggressively.
As seen with the current cases, once injected, the fungus can travel through the body's tissues rapidly, leading to invasive mycosis. However, the incubation period from exposure to disease could be up to six months, so exposed patients will need to be followed for a long time. While there were many people exposed to the fungus in 2002, all but one fatal case were successfully treated with voriconazole.
Treatment decisions should be made on a case-by-case basis, but the author writes that evidence from the previous outbreak suggests voriconazole as the logical antifungal drug for initial treatment. Due to the aggressive and deadly nature of the disease, it is important for physicians to act decisively and early.
The author warns that these outbreaks will happen again if pharmacy societies, the FDA, and the pharmaceutical industry do not work together to regulate pharmacy compounding.
- John R. Perfect. Iatrogenic Fungal Meningitis: Tragedy Repeated. Annals of Internal Medicine, 2012; [link]
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