The authors' affiliations are listed in the Appendix.
N Engl J Med. 2013 Oct 24;369(17):1610-9. doi: 10.1056/NEJMoa1304879.
Since September 18, 2012, public health officials have been investigating a large outbreak of fungal meningitis and other infections in patients who received epidural, paraspinal, or joint injections with contaminated lots of methylprednisolone acetate. Little is known about infections caused by Exserohilum rostratum, the predominant outbreak-associated pathogen. We describe the early clinical course of outbreak-associated infections.
We reviewed medical records for outbreak cases reported to the Centers for Disease Control and Prevention before November 19, 2012, from the six states with the most reported cases (Florida, Indiana, Michigan, New Jersey, Tennessee, and Virginia). Polymerase-chain-reaction assays and immunohistochemical testing were performed on clinical isolates and tissue specimens for pathogen identification.
Of 328 patients without peripheral-joint infection who were included in this investigation, 265 (81%) had central nervous system (CNS) infection and 63 (19%) had non-CNS infections only. Laboratory evidence of E. rostratum was found in 96 of 268 patients (36%) for whom samples were available. Among patients with CNS infections, strokes were associated with an increased severity of abnormalities in cerebrospinal fluid (P<0.001). Non-CNS infections were more frequent later in the course of the outbreak (median interval from last injection to diagnosis, 39 days for epidural abscess and 21 days for stroke; P<0.001), and such infections developed in patients with and in those without meningitis.
The initial clinical findings from this outbreak suggest that fungal infections caused by epidural and paraspinal injection of a contaminated glucocorticoid product can result in a broad spectrum of clinical disease, reflecting possible variations in the pathogenic mechanism and in host and exposure risk factors. (Funded by the Centers for Disease Control and Prevention.).
自 2012 年 9 月 18 日以来，公共卫生官员一直在调查在接受硬膜外、脊柱旁或关节注射受污染的醋酸甲泼尼龙的患者中发生的真菌性脑膜炎和其他感染的大规模暴发。对于由优势暴发相关病原体罗托沙姆耳霉引起的感染知之甚少。我们描述了暴发相关感染的早期临床病程。
我们复习了 2012 年 11 月 19 日前向疾病预防控制中心报告的来自六个报告病例最多的州（佛罗里达州、印第安纳州、密歇根州、新泽西州、田纳西州和弗吉尼亚州）的暴发病例的医疗记录。聚合酶链反应检测和免疫组织化学检测对临床分离株和组织标本进行了病原体鉴定。
在本项调查中，纳入的 328 例无外周关节感染的患者中，265 例（81%）患有中枢神经系统（CNS）感染，63 例（19%）仅有非 CNS 感染。268 例可供检测样本的患者中有 96 例（36%）有罗托沙姆耳霉的实验室证据。在患有中枢神经系统感染的患者中，中风与脑脊液异常程度增加有关（P<0.001）。非 CNS 感染在暴发后期更为常见（硬膜外脓肿和中风的从末次注射到诊断的中位间隔分别为 39 天和 21 天；P<0.001），而且这些感染发生在有和没有脑膜炎的患者中。
本次暴发的初步临床发现表明，受污染的糖皮质激素产品硬膜外和脊柱旁注射引起的真菌性感染可导致广泛的临床疾病谱，反映出可能存在的发病机制以及宿主和暴露风险因素的差异。（由疾病预防控制中心资助）。
