Part 6: 2023 Fungal Meningitis Outbreak

Fungal Meningitis Deaths Linked to Surgical Facilities in Mexico

By Cesar Collado

Fungal meningitis is a rare but serious medical condition characterized by the inflammation of the meninges, which are the protective membranes that cover the brain and spinal cord. Fungal meningitis is unlike bacterial or viral meningitis, which are more common. Fungal meningitis is caused by fungi and is not contagious from person to person.

The symptoms of fungal meningitis are like those of other types of meningitis and may include severe headaches, fever, stiff neck, nausea, vomiting, sensitivity to light, and altered mental status.

Fungal meningitis can occur when fungal pathogens enter the body through various means, such as:

• Direct Infection: Fungal spores or particles can enter the body through a penetrating injury, surgery, or medical procedures that involve the central nervous system.
• Spread from Other Infections: Fungal infections in other parts of the body can sometimes spread to the central nervous system, leading to fungal meningitis.
• Contaminated Medications: In some cases, fungal meningitis outbreaks have been linked medications administered through injections or spinal taps.

2023 Outbreak

An outbreak of fungal meningitis linked to two surgery clinics in Mexico appears to have claimed at least 12 lives to date. The Centers for Disease and Prevention updated its case tally, reporting ten confirmed or probable deaths linked to the outbreak.  These exposures are a concern to anyone who recently underwent epidural anesthesia at the clinics to seek immediate medical attention.

The outbreak first caught the attention of CDC and local health officials from Texas in early May. Two female patients in the state had been hospitalized with meningitis. [1]

 

Medical Tourism

Medical tourism involves US residents seeking elective surgery in Mexico due to lower costs.  Despite the risks, medical tourism is a booming business. Around 150,000 to 320,000 Americans travel abroad annually to undergo a medically necessary or an elective procedure, according to U.S. government figures. [2]

Cause of Outbreak

The outbreak has been traced back to the two surgical clinics in Matamoros, Mexico.  It is likely that either the needle or the anesthesia drugs themselves were not sterile and were contaminated with fungi that were injected directly into the cerebrospinal fluid—a straight shot to the brain. [3] Both the River Side Surgical Center and Clinica K-3 were shut down by health authorities on May 13, 2023. The fusarium solani species of fungus appeared to be present at both the clinics.

While it is not clear how many patients are hospitalized across the country, most of the patients are young women from 23 states in the United States who went to the clinics for cosmetic surgery procedures between Jan. 1 and May 1.   A majority of those exposed, however, were from Texas. 

Cases	Case Counts
Persons under investigation (People with no symptoms or symptoms are unknown, spinal tap results pending or unknown)	151
Suspected cases (Symptoms consistent with meningitis, spinal tap results pending or unknown)	9
Probable cases (Spinal tap results suggest meningitis; fungus not isolated)	14
Confirmed cases (Fungus detected from samples)	10
Deaths	12

Source: CDC.  https://www.cdc.gov/hai/outbreaks/meningitis-epidural-anesthesia.html

Other Fungal Meningitis Outbreaks

In 2012-2013, an outbreak in the northeast US was traced to a New England Compounding Center in Massachusetts, where injectable methylprednisolone acetate products were contaminated with the predominant pathogen, Exserohilum rostratum. As of October 23, 2013, the final case count stood at 751 patients exposed (?) and 64 deaths. [4]

Unusual Complications in Fungal Meningitis [5]

• Some patients who appear to be recovering with treatment suddenly get sicker.  
• Symptoms of fungal meningitis, unlike bacterial or viral meningitis, typically take weeks or longer to appear. Some fungal infections can take up to a year to show symptoms.
• Many patients do not disclose procedures to regular physicians.Most are not been tested to look for signs of meningitis. 
• The testing requires a spinal tap or lumbar puncture to access cerebral spinal fluid.This test is invasive and perceived to be a significant procedure where complications may arise.

The current outbreak is thought to be caused by a relatively rare organism, Fusarium solani.   The specific strain that has been isolated from only a portion of patients.

Surprising Complication from Fungal Meningitis 

It has been observed that infected patients have problems with blood vessels in the brain and/or neurovascular complications.  These include issues such as spasms of the arteries in the brain or an infection of the walls of the blood vessels themselves, known as a mycotic aneurysm.

• Some patients had appeared to be doing well on treatment but suddenly took a turn for the worse.It looks like a stroke where they suddenly can go unconscious.
• The aneurysms and the spasms are occurring around the brainstem. The pathology is currently not known.
• Antifungal medications are toxic chemicals that can cause problems in the liver, including liver failure.These medications must be monitored very closely.

Conclusions

Meningitis is a serious ailment where inflammation (swelling) of the protective membranes covering the brain and spinal cord occurs.

• Bacterialmeningitis is serious. Some people with the infection die, and death can occur in as little as a few hours. However, most people recover from bacterial meningitis with the utilization of antibiotic therapy.
• Viral meningitis (when meningitis is caused by a virus) is the most common type of meningitis. Most people get better on their own without treatment.
• Fungal meningitis is rare and usually develops after a fungal infection spreads from somewhere else in the body to the brain or spinal cord. The most common infecting fungi include Cryptococcus, Histoplasma, Blastomyces, Coccidioides, and Candida.

The treatment for fungal meningitis typically involves antifungal medications, which can be administered intravenously (IV) or directly into the cerebrospinal fluid through a lumbar puncture. The specific treatment and duration may vary depending on the type of fungus causing the infection and the patient’s overall health.

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1. Cohen, Elizabeth. “Seven People Dead in Connection with Fungal Meningitis Outbreak Linked to Surgeries in Mexico.” CNN News.June 29, 2023
2. Malhi, Sabrina.“Fungal meningitis outbreak kills 7 people; CDC urges testing.”  The Washington Post.  June 29, 2023
3. “Fungal Meningitis Outbreak Associated with Procedures Performed under Epidural Anesthesia in Matamoros, Mexico” CDC.org
4. Abbas, KM, et.al. “Clinical Response, Outbreak Investigation, and Epidemiology of the Fungal Meningitis Epidemic in the United States: Systematic Review.” Disaster Med Public Health Prep. 2016 Feb;10
5. Syal, Akshay MD.“Some patients in fungal meningitis outbreak have surprising complications” ABC News, July 3, 2023.