Exserohilum rostratum acquired by contaminated injections linked with broad disease

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1. Based on experience from the largest health care-associated outbreak, Exserohilum rostratum commonly results in meningitis, epidural abscess and arachnoiditis when introduced through epidural and paraspinal injections. 

2. Death from this outbreak was strongly associated with patients that experienced strokes. 

Evidence Rating Level: 4 (Below Average)          

Study Rundown: The largest health care-associated outbreak of Exserohilum rostratum occurred in September 2012, after patients received epidural, paraspinal and joint injections from a contaminated lot of methylprednisolone acetate. This study documented the clinical conditions that arose from this outbreak, which included fungal meningitis, stroke and epidural abscess. 

E. rostratum – typically a rare human pathogen – was the most frequently isolated organism in these patients. Infection likely resulted from a combination of direct spread from the site of injection coupled with suppression of normal host immunity by the steroid.

Among 328 patients included in this study, the three most common disease types observed were: meningitis, epidural abscess, and arachnoiditis. Stroke was the most common cause of death in this outbreak and for those that experienced strokes, the vertebrobasilar vessel was most commonly involved.

This study described the various clinical manifestations of fungal infections that can be introduced from epidural and paraspinal injections. While it is a comprehensive review of the recent outbreak, limitations include the size of the study, the geographic restrictions of data from only six states as well as the fact that E.rostratum was only isolated in 36% of patients in this study. Therefore, the clinical presentation trends cannot be completely attributed to infection with this species.

Click to read the study, published today in NEJM

In-Depth [case series]: This study included 328 patients who received epidural, paraspinal, or joint injections from contaminated lots of methylprenisolone acetate after May 21, 2012. Disease types within these patients included both central nervous system (CNS) disease (81%) and non-CNS disease (19%). The most common disease types were meningitis (N=250), epidural abscess (N=90) and arachnoiditis (N=63). Samples were obtained from 268 of 328 patients for testing, of which 96 (36%) had laboratory evidence of E. rostratum.

For the 30 patients diagnosed with stroke and localizable symptoms, arterial involvement included vertebrobasilar, basal ganglia and cerebral cortex (77%, 53%, 3%, respectively). The time interval from injection to diagnosis was shortest for stroke and longest for epidural abscess (median of 21 v. 39 days, p<0.001). Among the 26 deaths that occurred, 85% of these patients experienced a stroke.

By Jonathan Liu, MD and Adrienne Cheung

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