title: An outbreak of Aspergillus meningitis following spinal anaesthesia for caesarean section in Sri Lanka: a post-tsunami effect?
abstract: An outbreak of Aspergillus fumigatus meningitis occurred in 5 women following spinal anaesthesia, performed between 21 June and 17 July 2005 for caesarean section, in Colombo, Sri Lanka. The patients' median age was 27 years. Different teams in 2 maternity hospitals gave spinal anaesthesia. Mean incubation period was 11.2 days. Fever, headache and nuchal rigidity were common presentations. Remittent fever continued despite broad-spectrum intravenous antibiotics. Papilloedema, lateral rectus palsy, cerebral infarction and haemorrhage developed later. Three patients died. Cerebrospinal fluid pleocytosis with low glucose yielded negative PCR for fungi. Fungal cultures subsequently grew Aspergillus fumigatus. A post-mortem of the first patient confirmed Aspergillus meningitis, followed by treatment with amphotericin B and voriconazole, that saved the lives of others. Visual and hearing impairment in one and complete recovery in the other were observed a year after treatment. Examination of unused plastic syringes, needles, cannulae, and ampoules of anaesthetic agents confirmed that 43 syringes from three different manufactures were contaminated with Aspergillus fumigatus. The stores for drugs and devices of the Ministry of Health were examined and found to be full of tsunami donations, while regular procurements of the Ministry were kept in a poorly maintained humid warehouse. Inadequate space for tsunami donations was identified as the most plausible explanation for sub-optimal storage. Withdrawal and incineration of all unused syringes controlled the outbreak. The survival of those aggressively treated for Aspergillus meningitis suggests in hindsight that the availability of diagnostic tests and specific treatment, and early recognition of the outbreak could have saved the lives of victims who died. Early life-threatening side-effects and permanent long term sequelae of antifungal medication stress the need to be cautious with empirical treatment in immuno-competent low-risk individuals.
authors.affiliation: National Hospital of Sri Lanka. pagunara@hotmail.com
authors.forename: P S
authors.initials: PS
authors.lastname: Gunaratne
authors.forename: C N
authors.initials: CN
authors.lastname: Wijeyaratne
authors.forename: P
authors.initials: P
authors.lastname: Chandrasiri
authors.forename: S
authors.initials: S
authors.lastname: Sivakumaran
authors.forename: K
authors.initials: K
authors.lastname: Sellahewa
authors.forename: P
authors.initials: P
authors.lastname: Perera
authors.forename: R
authors.initials: R
authors.lastname: Fernando
authors.forename: J
authors.initials: J
authors.lastname: Wanigasinghe
authors.forename: S
authors.initials: S
authors.lastname: Jayasinghe
authors.forename: R
authors.initials: R
authors.lastname: Ranawala
authors.forename: M T M
authors.initials: MT
authors.lastname: Riffsy
authors.forename: H R
authors.initials: HR
authors.lastname: Seneviratne
mesh_terms: D000328:Adult; D000775:Anesthesia, Spinal / Q000009:adverse effects*; D001228:Aspergillosis / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D001230:Aspergillus / Q000302:isolation & purification*; D002585:Cesarean Section / Q000009:adverse effects*; D004190:Disasters; D004196:Disease Outbreaks; D004340:Drug Contamination; D004356:Drug Storage; D005260:Female; D006771:Hospitals, Maternity; D006801:Humans; D016921:Meningitis, Fungal / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D011247:Pregnancy; D012189:Retrospective Studies; D013188:Sri Lanka / Q000453:epidemiology; D013997:Time Factors