A nationwide outbreak of fungal infections was traced to injection of Exserohilum contaminated methylprednisolone Acetate (MA). We describe our experience with patients who developed peripheral osteoarticular infections following injection of contaminated MA.
Data were assembled from a hospital fungal outbreak registry, electronic medical records & magnetic resonance imaging (MRI) reports.
A total of 625 patients were exposed to contaminated MA at a nearby pain clinic. Of these patients, 49 (8%) received peripheral joint injection & 10 (20%) had proven or probable fungal infection at the injection site. The median time from last injection to diagnosis was 87 days (range: 28 to 201 days). Joints involved were: Hip (5), shoulder (4), ankle (1). Worsening pain was the presenting complaint in 9 patients; 2 had joint effusion, 6, decreased range of motion, & 3 fevers, chills, & night sweats. Arthrocentesis in 7 patients showed 14-24,000 WBC. MRI showed osteomyelitis in 7 & findings suggesting septic arthritis in 8.
All 10 patients underwent surgery. Findings included purulence (3), bone erosion (2), phlegmon (2), & synovial thickening (3). PCR for Exserohilum was positive on tissue samples in 3/9 patients. Histopathological findings in 8 specimens showed osteomyelitis in 3, synovitis in 3, abscess in 1, & granulomas in 1. Hyphae were seen in 1 specimen & that specimen also yielded Exserohilum on culture. Serum beta-D-glucan (BDG) was positive at 119 and 151 pg/mL in 2/7 patients both of whom had proven fungal infection.
All patients were treated with voriconazole. Seven of 10 were changed to itraconazole after a mean of 82.6 days. One patient with a positive PCR on the surgical specimen stopped his antifungal after 44 days due to intolerance. The other 9 were treated for a mean of 179.8 days (range 184 – 504 days). None have relapsed. Three patients underwent femoral head removal with spacer placement at the time of the first surgery. All three had successful second stage hip arthroplasty at a later date.
We describe the clinical, surgical, laboratory findings, & treatment in 10 patients with proven or probable fungal osteoarticular infections following injection with contaminated MA.
C. A. Kauffman, None