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Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report
George Nelson, Olga Fermo, Kiran Thakur
1Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. dsulliva@jhsph.edu.
Background:
In the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality.
Case Presentation:
We report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment.
Conclusions:
This is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.
Insights
This case report details the successful medical management of fungal meningitis and a cerebral mycotic aneurysm in an immunocompetent patient. The study highlights the potential utility of cerebrospinal fluid (1,3)-beta-D-glucan in diagnosing fungal infections.
Area of Science:
- Neurology
- Infectious Diseases
- Mycology
Background:
- Recurrent outbreaks of fungal infections linked to contaminated steroid injections from compounding pharmacies have occurred.
- The 2012 outbreak caused widespread central nervous system infections and fatalities, with Exserohilum rostratum identified as a primary pathogen.
- Cerebral phaeohyphomycosis presents a significant risk of morbidity and mortality.
Observation:
- A 41-year-old immunocompetent woman developed fungal meningitis after a contaminated methylprednisolone injection.
- Diagnosis was confirmed by cerebrospinal fluid pleocytosis and positive (1,3)-beta-D-glucan, despite negative cultures and PCR.
- She subsequently developed a superior cerebellar artery mycotic aneurysm and stroke symptoms.
Findings:
- Successful resolution of the cerebral mycotic aneurysm and stroke symptoms was achieved with antifungal treatment.
- This case represents a rare instance of successful medical management for this condition.
- Cerebrospinal fluid (1,3)-beta-D-glucan proved valuable in diagnosing fungal meningitis when other methods were negative.
Implications:
- The findings suggest that cerebrospinal fluid (1,3)-beta-D-glucan may be a useful biomarker for diagnosing and monitoring fungal meningitis.
- Further research is warranted to establish the diagnostic and prognostic utility of this biomarker.
- This case underscores the importance of vigilance and prompt diagnosis in managing fungal infections from contaminated medical products.
