title: Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate.
abstract: OBJECTIVE
  Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection.
  
  
  OBJECTIVE
  To determine if patients who had not presented for medical care but who had received contaminated methylprednisolone developed spinal or paraspinal infection at the injection site using contrast-enhanced magnetic resonance imaging (MRI) screening.
  
  
  METHODS
  There were 172 patients who had received an injection of contaminated methylprednisolone from a highly contaminated lot (No. 06292012@26) at a pain facility but had not presented for medical care related to adverse effects after the injection. Screening MRI was performed between November 9, 2012, and April 30, 2013.
  
  
  METHODS
  Number of persons identified with previously undiagnosed spinal or paraspinal infection.
  
  
  RESULTS
  Of the 172 patients screened, MRI was abnormal in 36 (21%), showing epidural or paraspinal abscess or phlegmon, arachnoiditis, spinal osteomyelitis or diskitis, or moderate to severe epidural, paraspinal, or intradural enhancement. Of the 115 patients asked about new or worsening back or neck pain, lower extremity weakness, or radiculopathy symptoms, 35 (30%) had at least 1 symptom. Thirty-five of the 36 patients with abnormal MRIs met the Centers for Disease Control and Prevention (CDC) case definition for probable (17 patients) or confirmed (18 patients) fungal spinal or paraspinal infection. All 35 patients were treated with antifungal agents (voriconazole, with or without liposomal amphotericin B), and 24 required surgical debridement. At the time of surgery, 17 of 24 patients (71%), including 5 patients who denied having symptoms, had laboratory evidence of fungal infection.
  
  
  CONCLUSIONS
  Among patients who underwent screening MRI to look for infection at the site of injection of contaminated methylprednisolone, 21% had an abnormal MRI, and all but one met CDC criteria for probable or confirmed fungal spinal or paraspinal infection. Screening MRI led to identification of patients who had minimal or no symptoms of spinal or paraspinal infection and allowed early initiation of medical and surgical treatment.
authors.affiliation: Section of Infectious Diseases, St Joseph Mercy Hospital, Ann Arbor, MI, USA. malania@trinity-health.org
authors.forename: Anurag N
authors.initials: AN
authors.lastname: Malani
authors.forename: David M
authors.initials: DM
authors.lastname: Vandenberg
authors.forename: Bonita
authors.initials: B
authors.lastname: Singal
authors.forename: Michael
authors.initials: M
authors.lastname: Kasotakis
authors.forename: Spencer
authors.initials: S
authors.lastname: Koch
authors.forename: Varsha
authors.initials: V
authors.lastname: Moudgal
authors.forename: Rajasekhar
authors.initials: R
authors.lastname: Jagarlamudi
authors.forename: Anupama
authors.initials: A
authors.lastname: Neelakanta
authors.forename: Michael H
authors.initials: MH
authors.lastname: Otto
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Halasyamani
authors.forename: Rami
authors.initials: R
authors.lastname: Kaakaji
authors.forename: Carol A
authors.initials: CA
authors.lastname: Kauffman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001416:Back Pain / Q000188:drug therapy; D004196:Disease Outbreaks; D004340:Drug Contamination; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008403:Mass Screening; D008581:Meningitis / Q000453:epidemiology / Q000209:etiology; D008775:Methylprednisolone / Q000008:administration & dosage / Q000009:adverse effects*; D008875:Middle Aged; D012307:Risk Factors; D018461:Soft Tissue Infections / Q000175:diagnosis* / Q000209:etiology; D013122:Spinal Diseases / Q000175:diagnosis* / Q000209:etiology; D055815:Young Adult
chemical_list: D005938:Glucocorticoids; D008775:Methylprednisolone