華陀再世
一個中國醫學生(CMG)在美國的生活。。。
嘴突臍孢（Exserohilum rostratum）
這批受真菌汙染的類固醇針劑已經在9月26日被召回。新英格蘭化合中心（New England Compounding Center）共有3個批次的產品涉及腦膜炎疫情，目前仍有另兩批次的產品在接受檢測。
新英格蘭化合中心現已暫時關閉，接受美國政府調查。該中心被懷疑違反規定，製造大批藥劑。根據規定，他們隻被授權根據醫生處方，定做特殊藥劑以滿足患者的個人需求。
據悉，所有腦膜炎感染者都曾因為背痛接受過類固醇注射治療。美國聯邦衛生官員透露，估計在全美23州的1萬4千人注射了這批次的類固醇。醫學專家表示，目前尚不知道會有多少人會發病，因為腦膜炎症狀可能要等幾個月才會出現。類固醇針劑主要用於醫治背脊和關節疼痛。
美國疾病預防控製中心(CDC)表示，這種真菌性腦膜炎不會傳染。當局建議所有曾注射過此類固醇的病人密切關注自己是否出現腦膜炎症狀，包括劇烈頭痛、惡心、發燒、言語不清以及行走困難等。患者如不及時獲得醫治，可導致永久性腦損傷或死亡。
根據美國疾病預防控製中心發布的數據，截至18日為止，確診感染腦膜炎病例涉及15個州的257人，總死亡人數上升至20人。
[病例分析]
In the case published in Annals of Internal Medicine, the 51-year-old patient, who had a history of neck pain, hyperlipidemia, headaches, and fibromyalgia, presented to a local emergency department with new occipital headache radiating to the face 1 week after a cervical epidural steroid injection on August 31, 2012.
It was her first steroid injection for neck pain.
She had no history of immune compromise or trauma and was not taking any long-term medications. Physical examination and computed tomography of the head were normal, and she was discharged. No lumbar puncture was performed.
The woman returned to the emergency department the following day with diplopia, vertigo, nausea, and ataxia and was hospitalized. Physical examination was notable only for hoarseness and decreased tendon reflexes; routine serum chemistry and blood counts were normal, and she had no fever.
Magnetic resonance imaging (MRI) of the brain on her first day in the hospital was normal. By day 3, she remained afebrile but developed slurred speech, right hemiparesis, left facial droop, and anisocoria, prompting a second MRI, which showed a punctate focus of diffusion restriction in the pons, the team says.
Lumbar puncture revealed a glucose level of 1.998 mmol/L (36 mg/dL) (serum glucose level of 5.828 mmol/L [105 mg/dL]), total protein level of 153 mg/dL, and white blood cell count of 850 × 109 cells/L (84% neutrophils and 15% lymphocytes); results of Gram stain and bacterial culture were negative.
On day 4, treatment with acyclovir, cefepime, vancomycin, doxycycline, and methylprednisolone was initiated; however, she continued to deteriorate and developed dysphagia, leading to endotracheal intubation.
A third MRI showed multifocal areas of restricted diffusion in the pons, midbrain, and cerebellum and diffuse leptomeningeal enhancement.
Rapid Deterioration
Repeated lumbar puncture on day 7 showed a glucose level of 2.719 mmol/L (49 mg/dL) (serum glucose level of 8.436 mmol/L [152 mg/dL]), protein level of 104 mg/dL, and white blood cell count of 72 × 109 cells/L (64% neutrophils, 4% lymphocytes, and 4% monocytes).
Polymerase chain reaction testing of CSF was negative for herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, and West Nile virus, as were cryptococcal and histoplasma antigens and CSF bacterial culture.
Repeated MRI of the brain showed new restricted diffusion in the left anterior thalamus, progression of brainstem infarction and edema, and interval development of ventriculomegaly, prompting placement of an externalized ventricular drain that did not result in clinical improvement.
The clinicians say the patient's health continued to deteriorate rapidly over the next several days, until she died 10 days later. Exserohilum species was reported in the CSF on the day she died.
Autopsy revealed a grossly necrotic brainstem, and microscopic examination showed angioinvasive, septate fungal hyphae associated with diffuse vasculitis and hemorrhagic infarction in the brain and spinal cord.
In their report, Dr. Lyons and colleagues note that human disease caused by Exserohilum species is "rare," although most pathologically confirmed cases in the ongoing outbreak of fungal meningitis were caused by this fungus.
"Intriguing" First Case
In the new NEJM report discussing the index case, researchers report that the man, who was his 50s, had a history of degenerative lumbar disc and joint disease and presented with headache and neck pain that had become progressively worse over the course of 8 days. Four weeks before presentation, he had received the latest in a series of epidural steroid injections of methylprednisolone.
On the basis of initial evaluation, the patient began receiving vancomycin, ceftriaxone, ampicillin, and glucocorticoids and was admitted to the hospital. Routine bacterial cultures of the blood and CSF were negative, and the glucocorticoids were stopped. The patient's symptoms improved with antimicrobial therapy, and he was sent home to complete the course of vancomycin and ceftriaxone for presumed community-acquired meningitis.
He presented 1 week after discharge with worsening symptoms and was hospitalized. On day 7 the microbiology laboratory confirmed Aspergillus fumigatus. The patient died on hospital day 22.
"What's intriguing about this case report is that the mold causing meningitis was reported to be Aspergillus fumigatus, an organism that has not been detected in any of the subsequent 200-plus cases," write the authors of a review article also published today in NEJM, entitled, "Fungal Infections Associated with Contaminated Methylprednisolone Injections—Preliminary Report."
Although the primary pathogen appears to be E rostratum, "it is possible that other pathogens could emerge and it remains a mystery as to why the index case is the sole case in which A. fumigatus was detected," write Carol Kauffman, MD, from the Veterans Affairs Ann Arbor Healthcare System in Michigan and colleagues.
They say it is "encouraging" that clinically apparent disease has developed in only a small percentage of exposed patients.
The CDC is providing regular clinical guidance updates (and new updates) on the fungal meningitis outbreak and the clinician's role.
