Magnetic Resonance Imaging Screening to Identify Spinal and Paraspinal Infections Associated With Injections of Contaminated Methylprednisolone Acetate

Malani, Anurag N.; Vandenberg, David M.; Singal, Bonita; Kasotakis, Michael; Koch, Spencer; Moudgal, Varsha; Jagarlamudi, Rajasekhar; Neelakanta, Anupama; Otto, Michael H.; Halasyamani, Lakshmi; Kaakaji, Rami; Kauffman, Carol A.

doi:10.1001/jama.2013.6293

Cited by 27 publications

(9 citation statements)

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“…The diagnostic findings of fungal meningitis on spinal MRI are not well established. Some patients with spinal and paraspinal Exserohilum rostratum infections have been reported to exhibit similar nodules, although these lesions were limited to the leptomeninges and nerve roots from the lower lumbar through sacral level (6,7). Sacral nerve roots have also been found to be abnormal on T1-weighted images in patients with varicella-zoster virus (8) and herpes simplex virus 2 infections (9).…”

Section: Discussionmentioning

confidence: 99%

Voriconazole-responsive Disseminated Nodular Lesions on Spinal MRI

et al. 2015

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A 74-year-old woman was hospitalized due to dysuria, weakness and dysesthesia of the lower extremities. She was in an immunosuppressed state following the administration of methylprednisolone therapy for idiopathic interstitial pneumonia. Cerebrospinal fluid and blood cultures were negative, and no infectious biomarkers were found. A gadolinium (Gd)-enhanced T1-weighted image of magnetic resonance imaging (MRI) revealed disseminated nodular lesions along the spinal cord. We suspected a diagnosis of seronegative deep mycosis and initiated anti-fungal therapy with voriconazole, which subsequently alleviated all of the patient's symptoms and MRI findings. Therefore, the presence of Gd-enhanced disseminated nodules on spinal MRI may be a good marker of deep meningeal mycosis.

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Section: Discussionmentioning

confidence: 99%

Voriconazole-responsive Disseminated Nodular Lesions on Spinal MRI

et al. 2015

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“…It is likely that the proactive approach that we took to perform MRI imaging in exposed patients resulted in the earlier identification of cases. Because more patients were admitted with spinal or paraspinal infections, some of whom were being treated for meningitis, a program was implemented to reach out to all patients who had received injections with lot #06292012@26 to offer them a screening MRI of the injection site, regardless of the presence of symptoms [ 11 ]. This program led to the identification of probable spinal or paraspinal infection in 35 patients, 24 of whom ultimately underwent surgical intervention and 17 of whom had laboratory evidence of fungal infection.…”

Section: Discussionmentioning

confidence: 99%

“…Contrast-enhanced magnetic resonance imaging (MRI) studies were reviewed by 1 of 3 neuroradiologists who used standard definitions as noted previously to classify their findings [ 11 ]. In brief, the paraspinal space included paravertebral muscles, facet joints, and structural ligaments.…”

Section: Methodsmentioning

confidence: 99%

Spinal and Paraspinal Fungal Infections Associated With Contaminated Methylprednisolone Injections

Moudgal

Singal

Kauffman

et al. 2014

Open Forum Infectious Diseases

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Background. A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone.Methods. Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports.Results. Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection.Conclusions. We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.

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“…Severe complications, including spinal cord infarction and cerebral ischemia, are very rare and have only been described as case reports [42][43][44][45] . Several cases of fungal meningitis have been reported from the injection of contaminated compound methylprednisolone acetate [46] .…”

Section: Current State Of the Artmentioning

confidence: 99%

The Epidural Treatment of Sciatica: Its Origin and Evolution

et al. 2016

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Epidural injection with corticosteroids is a common treatment option for patients with lower back pain or sciatica. In this paper we review its origin and evolution. The first injections were given around 1900 in Paris by Jean Sicard (1872-1929) and Fernand Cathelin (1873-1945), who worked independently. They both injected small volumes of cocaine into the sacral hiatus. After a slow start, the epidural treatment of back pain and sciatica gradually spread to other parts of Europe and Northern America. In the early 1950s, corticosteroids were introduced for epidural use. Since the 1970s, there have been numerous clinical trials that show a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term. Despite an ongoing debate about effectiveness and safety, epidural injections remain popular.

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Magnetic Resonance Imaging Screening to Identify Spinal and Paraspinal Infections Associated With Injections of Contaminated Methylprednisolone Acetate

Cited by 27 publications

References 4 publications

Voriconazole-responsive Disseminated Nodular Lesions on Spinal MRI

Voriconazole-responsive Disseminated Nodular Lesions on Spinal MRI

Spinal and Paraspinal Fungal Infections Associated With Contaminated Methylprednisolone Injections

The Epidural Treatment of Sciatica: Its Origin and Evolution

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