Section of Infectious Diseases, St Joseph Mercy Hospital, Ann Arbor, MI, USA.
JAMA. 2013 Jun 19;309(23):2465-72. doi: 10.1001/jama.2013.6293.
Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection.
To determine if patients who had not presented for medical care but who had received contaminated methylprednisolone developed spinal or paraspinal infection at the injection site using contrast-enhanced magnetic resonance imaging (MRI) screening.
DESIGN, SETTING, AND PARTICIPANTS: There were 172 patients who had received an injection of contaminated methylprednisolone from a highly contaminated lot (No. 06292012@26) at a pain facility but had not presented for medical care related to adverse effects after the injection. Screening MRI was performed between November 9, 2012, and April 30, 2013.
Number of persons identified with previously undiagnosed spinal or paraspinal infection.
Of the 172 patients screened, MRI was abnormal in 36 (21%), showing epidural or paraspinal abscess or phlegmon, arachnoiditis, spinal osteomyelitis or diskitis, or moderate to severe epidural, paraspinal, or intradural enhancement. Of the 115 patients asked about new or worsening back or neck pain, lower extremity weakness, or radiculopathy symptoms, 35 (30%) had at least 1 symptom. Thirty-five of the 36 patients with abnormal MRIs met the Centers for Disease Control and Prevention (CDC) case definition for probable (17 patients) or confirmed (18 patients) fungal spinal or paraspinal infection. All 35 patients were treated with antifungal agents (voriconazole, with or without liposomal amphotericin B), and 24 required surgical debridement. At the time of surgery, 17 of 24 patients (71%), including 5 patients who denied having symptoms, had laboratory evidence of fungal infection.
Among patients who underwent screening MRI to look for infection at the site of injection of contaminated methylprednisolone, 21% had an abnormal MRI, and all but one met CDC criteria for probable or confirmed fungal spinal or paraspinal infection. Screening MRI led to identification of patients who had minimal or no symptoms of spinal or paraspinal infection and allowed early initiation of medical and surgical treatment.
注射受污染的甲基强的松龙导致了一场史无前例的全国范围的嗜麦芽寡养单胞菌真菌感染爆发，最初表现为脑膜炎和/或基底动脉中风。在注射部位，脊柱或脊柱旁感染的隐匿性发作已越来越多地被报道，并在接受受污染药物注射后数月发生。临床发现通常很微妙，与导致患者接受甲基强的松龙注射的原因相似。
通过增强磁共振成像（MRI）筛查，确定未接受医疗护理但接受了受污染的甲基强的松龙注射的患者是否在注射部位发生了脊柱或脊柱旁感染。
设计、地点和参与者：共有 172 名患者在疼痛治疗机构接受了受污染的甲基强的松龙注射（来自高度污染的批号 06292012@26），但在注射后未因不良反应接受医疗护理。在 2012 年 11 月 9 日至 2013 年 4 月 30 日期间进行了筛查性 MRI。
确定先前未诊断的脊柱或脊柱旁感染人数。
在接受筛查的 172 名患者中，36 名（21%）的 MRI 异常，显示硬膜外或脊柱旁脓肿或蜂窝织炎、蛛网膜炎、骨髓炎或椎间盘炎，或中重度硬膜外、脊柱旁或硬脊膜内增强。在 115 名被问及新出现或加重的背痛或颈部疼痛、下肢无力或神经根病症状的患者中，有 35 名（30%）有至少 1 种症状。36 名 MRI 异常患者中，有 35 名（30%）符合疾病控制与预防中心（CDC）对可能（17 例）或确诊（18 例）真菌性脊柱或脊柱旁感染的病例定义。所有 35 名患者均接受了抗真菌药物（伏立康唑，联合或不联合脂质体两性霉素 B）治疗，24 名患者需要手术清创。在手术时，24 名患者中有 17 名（71%），包括 5 名否认有症状的患者，有真菌感染的实验室证据。
在接受受污染的甲基强的松龙注射部位注射增强 MRI 以寻找感染的患者中，21% 的 MRI 异常，所有患者但 1 名符合 CDC 对可能或确诊的真菌性脊柱或脊柱旁感染的标准。筛查性 MRI 可识别出仅有轻微或无脊柱或脊柱旁感染症状的患者，并可早期开始进行医学和手术治疗。
