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The Centers for Disease Control and Prevention (CDC) has continued to receive new reports of fungal infections in patients who received contaminated methylprednisolone acetate (MPA) from the New England Compounding Center (NECC) months ago, according to a CDC clinical call on March 13.
Most of these cases have been localized spinal and paraspinal infections. To date, localized infections have occurred in 304 cases, followed by meningitis infections in 239, and then patients who present with both-localized fungal infections and meningitis infections (138), explained Tom Chiller, MD, CDC’s deputy chief of mycotic diseases branch.
“The fungal infections may be indolent for a long time,” Dr. Chiller said. “Clinicians need to remain vigilant in monitoring these patients as we are seeing patients with infections months after the injections were performed.”
Clinicians need to continue to monitor patients with minimal, if any, changes in symptoms from baseline and possibly consider an MRI at the site of injection, if clinically warranted, he explained.
CDC had issued a Health Alert Network (HAN) update on March 4th to re-emphasize the warning to clinicians about these new infections, even in patients who presented months earlier and tested negative for signs of fungal infection, Dr. Chiller warned.
“The incubation periods can be very prolonged. However, patients on treatment are getting better. We are trying to understand more about patients who are on therapy and how to monitor patients after therapy is stopped,” he said.
Voriconazole, the first-line treatment for these fungal infections, is usually started at a high dose of 6 mg/kg for 5 days and then the dose is adjusted for trough between 2 mg/kg and 5 mg/kg.
Dr. Chiller warned about the side effects with voriconazole, including hallucinations with the initial high dose. Some patients have also experienced nausea, anorexia, fatigue, chapped lips , alopecia, headaches, “a foggy feeling,” severe photosensitivity, and skin cancer.
“Our clinician consultation network is available to help in the management of these cases,” Dr. Chiller said. “If voriconazole and amphotericin B cannot be tolerated, some patients have received itraconazole or posaconazole. However, there has been limited experience with posaconazole.”
The CDC has been cautious about setting a treatment timeframe. Patients should be treated for at least 3 months, but probably up to 6 months. Others may need to be treated up to 1 year or longer, depending upon their response, he said.
“We have been able to treat most patients in the outpatient setting and they have been treated with voriconazole,” said Anu Malani, MD, from St. Joseph’s Mercy Medical Center, Ann Arbor, Mich, who answered questions during the CDC call.
Dr. Malani has continued to see new cases this week, which highlights the need to be vigilant in monitoring for symptoms and follow up with an MRI, if warranted.
Clinicians who are in need of more information for the clinical management of these infections can call the CDC at 1-800-232-4636. Someone from the clinical consultation network will return the calls.