CATES: Fungal meningitis outbreak

By Carol A. Cates, MSN, MBA, RN

Chief Nursing Officer

Odessa Regional Medical Center

In May of this year, two surgery centers in Matamoros, Mexico, River Side Surgical Center, and Clinica K-3, were closed because of an outbreak of fungal meningitis. The common denominator between everyone diagnosed is they all received epidural anesthesia at one of those two surgical centers for their procedure. Experts are still trying to figure out if the fungus that caused the infections came from contaminated supplies used in the insertion of the epidurals or if contaminated medications were injected.

Part of the issue with this outbreak is the time between when a person is infected and when they show symptoms can be months long. That’s why health care providers are concerned about people who had epidurals in these clinics as far back as January of this year. I am writing about this outbreak to help spread the word to those who may be affected and to help everyone understand what meningitis is and why its such a huge concern.

The meninges are tough layers of tissue that cover the brain and spinal cord to help protect them. There are 3 layers of tissue that comprise the meninges. In epidural anesthesia, narcotics, numbing medications, and/or anesthetic agents are injected into the lower spinal canal between the bones, tendons and muscles, and the outermost layer of the meninges. That spot is called the epidural space. Once injected, those drugs are slowly absorbed across the meninges into the nerves of the spinal cord causing the anesthetic effects needed. If anything used to access the epidural space or the medications injected are contaminated with bacteria, viruses, fungi, or other microorganisms it can cause an infection of that space, and that infection can easily spread to the meninges. An infection of the meninges is called meningitis.

The meninges are in many ways like the “silver skin” you will sometimes find on a piece of pork or beef. That tissue is very tough and protective of the structures around it. For the most part, that is a very good thing. But, if that tissue gets infected, the same structure that makes it tough also makes it hard for the body to fight an infection of those tissues. The other bad thing is that when tissue gets infected, it swells (think about if you get infected cut on your hand, the edges of the wound will swell).

Normally, that is a good thing, because the swelling helps the body bring more infection-fighting cells and chemicals to the site of the infection. But with the meninges that same swelling can be a very bad thing. It’s because the meninges aren’t the only things protecting the brain and spinal cord. Those structures are also protected by the bones of the skull and spine. When the meninges swell, because everything is surrounded by bone, the swelling can crush the delicate nerves that make up the brain and spinal cord. That crushing can cause brain or spinal cord damage and even death.

Symptoms of meningitis include fever, headache, a stiff neck, nausea and vomiting, light sensitivity, confusion, and other forms of altered mental status. Testing is done with MRI and by doing a procedure called a lumbar puncture where cerebrospinal fluid (the fluid that surrounds the brain and spinal cord between the meninges) is removed and tested for chemicals and microorganisms.

Treatment of fungal meningitis is with high-dose antifungal medications over several weeks to even months. While some types of meningitis can be spread from person to person, fungal meningitis cannot. Fungal meningitis happens when a fungal infection from elsewhere in the body spreads to the meninges surrounding the brain or spinal cord. In this outbreak, the fungus seems to have been directly injected into the epidural space.

An estimated 200 Americans went to those surgery centers between January and when they closed in May to have various procedures with epidural anesthesia. Those patients are at severe risk for fungal meningitis. So far 4 people in the US have died because of this outbreak. In other fungal meningitis outbreaks, half of the people who became infected died.

The Centers for Disease Control and Prevention (CDC) recommends that anyone who had a procedure in those surgery centers after January 1, 2023, and had epidural anesthesia, go to an emergency room to get tested for the infection, even if they are not having symptoms.

If you or someone you love has been to one of those surgery centers during that time, please go to an emergency room as soon as possible. The CDC is also recommending that anyone going to that area for health care “practice enhanced precautions” because they still haven’t figured out exactly where the source of the fungus has come from in terms of supplies or medications.