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Nearly six months after the start of a deadly fungal meningitis outbreak blamed on tainted pain shots, patients who originally tested clear are showing up sick. This is raising concern the incubation period for illness may be longer than anyone thought.
Though the flood of patients has slowed dramatically, two or three people each week are still reporting infections caused by contaminated steroids. According to officials with the Centers for Disease Control and Prevention, this outbreak has killed 48 people and sickened more than 700.
Among those new patients are people who received mold-tainted doses of the drug methylprednisolone, but who previously got MRIs or lumbar punctures that showed they were free of infection. These slow-growing infections aren’t as severe as fungal meningitis, but worrying nonetheless.
CDC officials issued a health alert this week urging clinicians to remain vigilant for new infections, even in people who show subtle symptoms – or none at all.
“We are seeing some patients with very long incubation periods,” said Dr. Tom Chiller, associate director for epidemiological science in the CDC’s division of foodborne, waterborne, and environmental diseases. “We expect to see people getting infections months after their injections.”
Nearly 14,000 people in 23 states were exposed to the contaminated drugs produced by the New England Compounding Center of Framingham, Mass. An estimated 11,000 actually received shots for back or neck pain, the CDC says. So far, 720 people in 20 states have fallen ill. Thus far, the state of Michigan has seen the most cases – 253 – in the outbreak.
Most of the seriously ill people – those with fungal meningitis infections that caused strokes, for instance – showed up within several weeks or one to two months starting in late September.
Back then, CDC officials told worried patients that the greatest risk for meningitis was likely in the first 42 days – six weeks – after the shots, suggesting they could breathe easy after the first week in November.
However, patients have continued to become ill, most often not with meningitis, but with infections at the injection site, with epidural abscesses or with a condition called arachnoiditis, an inflammation of the nerves near the spine.
Though doctors have little experience with such fungal infections, the incubation period appears to be stretching longer than a previous outbreak in 2002, when a patient became ill 152 days – five months – after getting a steroid shot.
At this time officials do not know how long the incubation period is. Originally, health officials told patients who received the tainted drug the biggest worry was after 90 days or so, but now they’re not so sure.
CDC officials want health workers to continue to monitor patients who received the shots, particularly those whose have pain that is worse or different from the initial symptoms. However, even patients who previously tested negative for infections and those with no apparent symptoms are still at risk.
“These infections may be unrecognized because some patients have not continued to receive close clinical follow-up or because they have not recognized symptoms suggestive of a localized infection,” the new alert says.
CDC recommends health workers have a low threshold for considering MRIs, or magnetic resonance imaging, to detect unseen infections.
Even patients who initially resisted MRIs because they didn’t want them or didn’t think they needed them have turned up with infections.
The danger of not detecting the infections is that they only will get worse. Any infection left untreated, can move beyond soft tissue to bone and eventually make its way to the central nervous system with devastating, even deadly, effects,
This raises the next question: How long should infected patients be treated? Some patients say they’ve been told three months, then nine months – then a year.
The primary drugs used to treat the fungus – voriconazole and amphotericin B – are both expensive and toxic, with a host of side effects ranging from hair loss and hallucinations to liver problems.
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