Fungal Meningitis: The New Iatrogenic
As natural disasters go, Hurricane Sandy was about as bad as it gets. But even as we come to expect that hurricanes will continue to arrive with greater frequency and ferocity, it is worth a pause to consider another disaster – this one wholly new, wholly unexpected, and wholly man-made.
I am speaking of the latest public health disaster: fungal meningitis.
Once upon a time, iatrogenic injury was a pretty straightforward, cut-and-dried occurrence. A surgeon cuts off the wrong leg. An overzealous doc plants a biopsy needle a little off base and severs a nerve. For worse or worst, there’s a mishap and it’s all the doctor’s fault.
And by iatrogenic, once can also include just plain practice errors where the patient suffers from being misdiagnosed, or placed on the wrong drug or has come to harm through a mistaken dosage. In all these instances, there is a degree of medical culpability for getting it wrong. Kind of like a certain Braves-Cards playoff game, when a ref gave the whole game to the Cards on a blown call.
But the fungal meningitis outbreak is both wholly new and decidedly not the doctor’s fault, despite being a medical mishap. While it may be appropriate to call into question the evidence supporting the benefit of steroid injections in the first place — if nothing else, people may start asking how appropriate and proven a treatment is — the epidemic stems not from physician error, but from contaminated drugs.
As is now known, the contamination occurred at the New England Compounding Center (NECC), an entity that started out as a mom-and-pop scaled pharmacy serving a niche market, but which grew too big to keep up with standard, basic safety procedures. For example, it was reported Oct 23, that the company shipped three lots of suspected drug vials before they got back sterility testing results.
Why is this an Emergency Medicine issue?
Not just because Shady Grove, Meritus and Southern Maryland Hospitals all received medications from NECC, but because so did a wide variety of Surgi-centers, Podiatrists, and a host of other practitioners in our communities as well. Our neighbors and friends are legitimately wondering if they are at risk.
It’s an ED issue because, in the words of a pain clinic doctor from Massachussetts (quoted on NPR’s Morning edition last week, “It’s the perfect mess.” The symptoms are vague and non-specific: headache, fever, meningismus. The CDC’s patient guide advises “talking to your doctor as soon as possible” if you have had an epidural steroid injection since May 21, 2012. That’s a lot of people. We are likely to be doing a lot more LPs, which is all well and good if the tap is normal. But what if there’s an increased cell count?
Currently, the CDC recommends empirical anti fungal therapy (Voriconazole) for six or more WBCs, in consultation with an infectious disease specialist. Cultures take a long time to grow, so we are likely to be treating many patients who ultimately have negative cultures.
The news will cycle on to other issues, (I think there’s a vote coming up), and the public’s anxiety will also migrate to other problems. But it’s the zombie-like quality that really bothers me about this. Physicians are the vectors for this new infection: we’re passing along a disease without knowing it and it won’t be the last time this happens.