Multistate outbreak of fungal meningitis among patients who underwent surgical procedures under epidural anesthesia in Matamoros, Mexico

Actions requested

• Be aware of a multistate outbreak of fungal meningitis among patients who underwent surgical procedures under epidural anesthesia at 2 clinics in Matamoros, Mexico – River Side Surgical Center and Clinica K-3.
• Early detection and treatment of fungal meningitis is critical to improving patient outcomes, particularly because patients whose symptoms are initially mild or absent may quickly worsen without treatment.
• No vaccine is available to prevent fungal meningitis.
  
  
• Evaluate all patients, including those without symptoms, who report procedures under epidural anesthesia at either clinic since January 1, 2023, for fungal meningitis.
• This recommendation is based on high case-fatality rate (>40%) of central nervous system Fusarium infections observed in a recent outbreak (Durango, Mexico) and the finding that some patients during the outbreak who had few or no symptoms were still found to have fungal meningitis based on CSF test results; fungal signals consistent with the Fusarium solani species complex have been detected from the CSF of patients receiving care in Mexico or the United States.
• Diagnostic lumbar puncture (LP), unless contraindicated, is recommended as part of clinical evaluation of exposed patients regardless of symptoms.
• An MRI of the brain with and without contrast is recommended for all exposed patients with abnormal LP results to assess for meningeal enhancement, vasculitis, stenosis, hemorrhage, or ischemia; for exposed patients with back pain or paresthesia, MRI with and without contrast of the spine is recommended to assess for local infection or meningeal enhancement; MRI of the brain is not required for patients with normal LP test results.
• Asymptomatic patients with normal LP results should continue to monitor for symptoms for at least 4 weeks. Consider repeating the LP after 2 weeks to ensure infection has not developed; if the patient has new or persistent symptoms, an LP should be repeated.
• To date, most cases have reported symptom onset ranges from 3 days to 4 weeks after the date of exposure.
• An algorithm for diagnosis and management is available and may be updated as additional information is available.
  
  
• Initiate treatment as soon as possible after obtaining CSF if fungal meningitis is suspected. Consultation with an infectious disease specialist is recommended.
• Treatment with aggressive, dual antifungal treatment with adequate central nervous system penetration is recommended. See Interim Recommendations
• Do not withhold treatment because of negative fungal culture or (1,3)-beta-D-glucan results.
• Interim diagnostic and treatment recommendations including additional testing, length of treatment and ongoing monitoring guidance are available and may be updated as additional information is available.
  
  
• Immediately report any suspected or laboratory-confirmed fungal meningitis cases who might be related to this outbreak to Public Health at 206-296-4774.