title: Vascular complications of fungal meningitis attributed to injections of contaminated methylprednisolone acetate.
abstract: OBJECTIVE
  Fungal meningitis due to injections of contaminated methylprednisolone acetate can present with vascular sequelae in immunocompetent individuals. This is particularly germane to neurologists because better recognition of the clinical characteristics of patients with fungal meningitis and ischemic stroke will provide more timely and efficient care.
  
  
  METHODS
  In a case series, 3 patients presented to Vanderbilt University Medical Center in Nashville, Tennessee, with acute ischemic stroke and later received a diagnosis of fungal meningitis attributed to epidural injections of contaminated methylprednisolone. Of these 3 patients, 2 were women, and the mean age for all 3 was 75.3 years. Their medical records and imaging scans were reviewed. All 3 patients presented with acute ischemic strokes and had a history of epidural spinal injections of methylprednisolone for low back pain. All 3 patients had 1 or more traditional risk factors for stroke. There were differing vascular patterns of presentation: 2 patients presented with small-vessel (lacunar) infarctions, whereas 1 patient presented with a large-vessel infarct. Of these 3 patients, 2 died and underwent an autopsy, which revealed Exserohilum rostratum as the presumed cause of death. For 2 cases, fever and meningeal signs were absent at presentation.
  
  
  CONCLUSIONS
  Patients with fungal meningitis may present with ischemic stroke detected on initial imaging scans. A definitive diagnosis should not delay early antifungal treatment.
authors.forename: Kirk
authors.initials: K
authors.lastname: Kleinfeld
authors.forename: Pearl
authors.initials: P
authors.lastname: Jones
authors.forename: Derek
authors.initials: D
authors.lastname: Riebau
authors.forename: Ariana
authors.initials: A
authors.lastname: Beck
authors.forename: Paisit
authors.initials: P
authors.lastname: Paueksakon
authors.forename: Ty
authors.initials: T
authors.lastname: Abel
authors.forename: Daniel O
authors.initials: DO
authors.lastname: Claassen
mesh_terms: D000368:Aged; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001921:Brain / Q000473:pathology; D004340:Drug Contamination / Q000517:prevention & control; D005260:Female; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects; D008297:Male; D016921:Meningitis, Fungal / Q000382:microbiology*; D008775:Methylprednisolone / Q000009:adverse effects / Q000031:analogs & derivatives*; D000077555:Methylprednisolone Acetate; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology*
chemical_list: D000893:Anti-Inflammatory Agents; D000935:Antifungal Agents; D000077555:Methylprednisolone Acetate; D008775:Methylprednisolone