CDC advises of fungal meningitis outbreak associated with procedures performed under epidural anesthesia in Matamoros, Mexico
The Centers for Disease Control and Prevention (CDC) has advised of an ongoing multistate outbreak of fungal meningitis among patients who received procedures under epidural anesthesia at two centers in Matamoros, Mexico during January 1–May 13, 2023.
Fungal signals consistent with the Fusarium solani species complex were detected in cerebrospinal fluid of patients receiving care. Given the potential high case-fatality rate of central nervous system Fusarium infections and the latency of symptom onset, the CDC advises that all exposed patients should receive a lumbar puncture to test for fungal meningitis, regardless of symptoms. To date, over 200 people in 25 states have been identified as being at risk, and four patients have died.
Interim guidance for the diagnosis and management of fungal meningitis associated with this outbreak is available and is being updated as the ongoing investigation develops. Fungus Education Hub: interim recommendations for diagnosis and management of cases of fungal meningitis associated with epidural anesthesia administered in Matamoros, Mexico Opens in new window
Summary
Definition
History and exam
Key diagnostic factors
- progressive headache
- severe headache
- meningismus
- symptoms of hydrocephalus (impaired cognitive function, confusion, coordination and gait disturbances, and urinary incontinence)
- behavioral or personality change
- reduced visual acuity and papilledema
Other diagnostic factors
- nausea or vomiting
- fever
- reduced conscious level
- cranial nerve palsies
- seizures
- weight loss
- mouth ulcers
- focal neurologic signs
- lymphadenopathy, hepatosplenomegaly
- dyspnea
- papular umbilicated skin lesions
- retinal defects
- nasal or palatal eschar
Risk factors
- HIV infection
- corticosteroid use
- underlying chronic disease (e.g., malignancy, organ failure, autoimmune disease, organ transplant)
- residing in or visiting northern Australia, Papua New Guinea, or Vancouver Island, Canada
- exposure to disturbed soil, chicken guano, or bat caves
- impaired cell-mediated immunity
- Filipinos and African Americans
- neutropenia or impaired phagocytic function
- neurosurgery
- infants and neonates
- central vascular catheters
- sinonasal disease
- antibacterial usage
- prior surgery
- hyperalimentation
- intravenous drug use
Diagnostic investigations
1st investigations to order
- CT and/or MRI head scan
- fungal blood cultures (3 sets)
- serum cryptococcal antigen test
- serum + urine Histoplasma antigen
- immunodiffusion tests (IgM and IgG) and complement fixation test (IgG) for coccidioidomycosis
- cerebrospinal fluid opening pressure
- cerebrospinal fluid (CSF) WBC and differential
- cerebrospinal fluid (CSF) protein
- cerebrospinal fluid (CSF) glucose
- cerebrospinal fluid India ink stain
- cerebrospinal fluid (CSF) culture
- cerebrospinal fluid cryptococcal polysaccharide antigen test
- cerebrospinal fluid Histoplasma antigen
- cerebrospinal fluid Histoplasma antibodies
- cerebrospinal fluid coccidioidal IgG antibodies
- cerebrospinal fluid (CSF) galactomannan antigen test
Investigations to consider
- histopathology and culture of biopsies: meningeal, brain, extraneural sites of involvement
- polymerase chain reaction (PCR)
Emerging tests
- 18F-fluorodeoxyglucose (FDG) PET/CT
- cerebrospinal fluid (CSF) (1-3)-beta-D-glucan
Treatment algorithm
cryptococcal meningitis
histoplasmal meningitis
coccidioidal meningitis
candidal meningitis
Exserohilum rostratum meningitis
Aspergillus meningitis
mucormycosal meningitis
Contributors
Authors
Abhijit Chaudhuri, DM, MD, PhD, FACP, FRCP (Glasg), FRCP (Lond)
Consultant Neurologist
Clinical Lead of Neuroinflammation
Department of Neurology
Queen's Hospital
Romford
UK
Disclosures
AC declares that he has no competing interests.
Acknowledgements
Dr Abhijit Chaudhuri would like to gratefully acknowledge Dr Thomas S. Harrison and Dr Angela Loyse, previous contributors to this topic.
Disclosures
TSH and AL declare that they have no competing interests.
Peer reviewers
Robert A. Larsen, MD
Associate Professor of Medicine
University of Southern California
Keck School of Medicine
Los Angeles
CA
Disclosures
RAL declares that he has no competing interests.
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- Tuberculous meningitis
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- Viral meningitis
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