Red Book Online Outbreaks: Fungal Meningitis Outbreak Associated with Procedures Performed under Epidural Anesthesia in Matamoros, Mexico

Overview

The United States Centers for Disease Control and Prevention (CDC), the Mexican Ministry of Health, and US state and local health departments are responding to a multinational outbreak of fungal meningitis among people who had procedures under epidural anesthesia in Matamoros, Tamaulipas, Mexico. Officials identified two clinics associated with the outbreak: River Side Surgical Center and Clinica K-3. These clinics were closed on May 13, 2023. Anyone who had procedures under epidural anesthesia in these clinics from January 1 to May 13, 2023, is at risk for fungal meningitis. (Fungal Meningitis Outbreak| CDC)

As of August 31, 2023, nearly 200 US residents were exposed to and 12 have died (three probable cases and nine confirmed cases) from meningitis. Fusarium solani species complex was detected by U.S. and Mexico laboratories.  The Mexican Ministry of Health provided CDC with a list of US residents who had procedures at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023. Using this list, CDC and state and local health departments are trying to reach all people at risk but continue to face challenges. Some of the listed contact information is incorrect or incomplete and some at-risk persons have been identified who were not on the list.  These people are being reached through outreach efforts like media and social media and through family, friends, and other contacts found during public health investigations.

Clinical Guidance

• Presentation: Exposed patients include those who underwent a procedure under epidural anesthesia at River Side Surgical Center and Clinica K-3 in Matamoros, Mexico, from January 1-May 13, 2023. Anyone who is at risk for fungal meningitis should go to the nearest emergency room right away to be tested, even if they do not have symptoms. Symptoms of fungal meningitis include fever, headache, stiff neck, nausea, vomiting, sensitivity to light, and confusion. It can take weeks for symptoms to develop, and they may be very mild or absent at first.  However, once symptoms start, they can quickly become severe and life-threatening.
• Consultation: If available, consultation with an infectious diseases physician and a neurologist is recommended to assist with diagnosis, management, and follow-up for patients diagnosed with fungal meningitis. Optimal therapy for these infections has not been established, varies between patients, and may be complex and prolonged.  Expert consultation is particularly important because overall clinical experience with these infections is highly limited.  Providers should contact their local health department if they have patients presenting for care. They can also contact CDC (fungaloutbreaks@cdc.gov). Public health officials can reach out to CDC to connect clinicians with experts in fungal meningitis management.
• Interim Recommendations: A lumbar puncture is recommended for all exposed patients, even those without symptoms, because Fusarium fungal meningitis has a >40% fatality rate and infection may have mild or no symptoms at first. Early treatment with antifungals can improve morbidity and mortality.
  • Perform fungal meningitis CSF diagnostic testing
    • Even if asymptomatic, patients should receive an initial LP (unless contraindicated, e.g., puncture site skin infection, brain mass causing increased intracranial pressure).
    • If LP results are abnormal, CSF testing should include beta-d-glucan (Fungitell®), as
      well as pan-fungal PCR or next-generation metagenomic sequencing; recommended testing is available in the Interim Recommendations.
    • Normal LP results: WBC count ≤5 cells/mm³ (account for RBC presence by subtracting 1 WBC for every 500 RBCs).
    • Abnormal LP results: >5 WBCs/mm³ (subtract 1 WBC for every 500 RBCs).
  • Normal initial LP results
    • Consider repeat LP 2 weeks after the initial LP.
    • If new or worsening meningitis symptoms within 30 days of initial LP, patient should immediately go to the ED for reevaluation, including an urgent repeat LP.
  • Abnormal LP results
    • Combination antifungal therapy with IV liposomal amphotericin B (AmBisome®),
      voriconazole, and fosmanogepix (requires IND). At least 3 months antifungal therapy
      recommended, but >6 months needed for severe cases.
    • Check serum voriconazole trough level (target 4–5 mcg/ml) day 5 of voriconazole (and at least weekly thereafter)
    • MRI with and without contrast for meningeal enhancement, vasculitis, stenosis, hemorrhage, and/or ischemia.
    • If available, consult infectious disease specialist, pharmacist, and/or neurologist to help management and patient follow-up due to:
      • Antifungal therapy side effects and voriconazole therapeutic drug monitoring.
      • Potential complications of fungal meningitis include elevated intracranial pressure, CNS vasculitis, brain edema, strokes, and intracranial hemorrhage.
    • Adjust treatment, monitor for symptoms, and manage complications; clinicians should anticipate the need for outpatient antimicrobial therapy and close outpatient follow-up.

• Reporting: Suspected cases should be reported to the local or state department of public health.

Resources

• For more information see the Red Book chapter: Other Fungal Diseases, which includes information on Fusarium