MRI screening for fungal infection from methylprednisone injections

Image: PD Exserohilum rostratum

1. MRI screening of patients receiving an injection of contaminated methylprednisone indicated that 21% had a clinically significant lesion. 

2. Earlier detection of lesions presumably allows for earlier initiation of medical or surgical management of sequelae of fungal infection.

Evidence Rating Level: 2 (Good) 

Study Rundown: Contaminated methylprednisolone injections recently caused a widespread fungal outbreak that was widely reported by the press. The first wave of manifestations among patients was fungal meningitis. Since the initial wave of meningitis, there has been an increasing prevalence of spinal and paraspinal infections, which can present long after the initial injection. Furthermore, these patients who develop late spinal and paraspinal infections are not always symptomatic, especially since it can be difficult to distinguish symptoms from the patient’s baseline back pain. The authors of the study utilize MRI as a screening tool to identify spinal and paraspinal infections among patients who received methylprednisone injections from the infected batches.

There are several limitations of the study. First, the authors assume that earlier identification of infected patients will produce better outcomes but this has not been definitively proven. Another weakness is that there is no clear known mechanism by which Exserohilum rostratum alone, the fungal agent identified as the culprit organism in the outbreak, would cause asymptomatic deep infections. Nonetheless, the study indicates that MRI represents an effective modality to screen for underlying fungal infection among asymptomatic patients who received contaminated methylprednisone injections.

Click to read the study, published today in JAMA

Click to read an accompanying editorial, published today in JAMA

Relevant Reading: Multistate outbreak of fungal infection associated with injection of methylprednisolone acetate solution from a single compounding pharmacy

Dr. Anurag M. Malani speaks to 2MinuteMedicine: “Providers must continue to be vigilant when following patients who have received spinal or paraspinal injections of contaminated methylprednisolone.   Clinical symptoms of localized spinal or paraspinal infection can be subtle and difficult for patients to distinguish from underlying chronic pain.”

In-Depth [prospective trial]: In this prospective trial, a total of 172 patients, all of whom had received at least 1 injection from a highly contaminated batch of methylprednisolone, were screened with MRI. The aim was to identify all patients who had previously undiagnosed spinal or paraspinal infections secondary to the fungus Exserohilum rostratum. Screening MRIs were classified as abnormal (n=36), equivocal (n=18), or normal (n=118). Abnormal studies, in order of decreasing frequency, included evidence of phlegmon, abscess, spinal osteomyelitis or diskitis, and arachnoiditis. Thirty five out of 36 of these patients met the CDC definition for probable spinal or paraspinal infection. Seventeen out of 36 of these patients had confirmed evidence of fungal infection. All 36 patients with abnormal MRIs were treated with voriconazole +/- liposomal amphotericin B.

By Anne Marie Walters and Rif Rahman

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