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The Boston Globe

Health & wellness

As death toll rises, outbreak’s first case detailed

The fungal meningitis outbreak that has now infected more than 271 people and killed 21 was first identified in a Tennessee man in his 50s, whose harrowing and tragic struggle against the disease has now been detailed in the New England Journal of Medicine.

The report published online Friday provides a window into how the outbreak was first identified and clues as to why it has been a complicated public health problem for doctors and investigators to fully unravel. The first identified case of what doctors later realized was an unprecedented outbreak of a very unusual illness was caused by a mold called Aspergillus fumigatus , while the underlying cause of most of the other cases subsequently identified was a black mold called Exserohilum rostratum .

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A team of doctors from Vanderbilt University School of Medicine described their patient as a middle-aged man who had a history of back and joint problems. He developed symptoms that began with a headache and neck pain four weeks after receiving epidural injections of a steroid made by New England Compounding Center.

The patient was admitted to the hospital, treated, and improved. He went home with drugs “for presumed community-acquired meningitis,” a more typical form of the disease, according to the case report.

A week later, when he returned to the hospital, the man’s condition had taken a disturbing turn for the worse. “He appeared ill, uncomfortable, and agitated, with incomprehensible speech,” the article reports. A lumbar puncture was performed and treatment with antibiotics was started.

“By hospital day 2, his mental status was markedly improved,” the doctors reported. But four days later, the patient’s condition had worsened. He was experiencing “intermittent staring spells,” had developed a droop on the right side of his face, and was drowsy. Extensive tests were performed, and the next day, the laboratory found that fluid taken from his spine on the first day he was admitted to the hospital was contaminated with Aspergillus fumigatus.

By day 11, the case report states, the man “abruptly became unresponsive, with rhythmic shaking of the head that was consistent with seizure activity.” He was put on a ventilator, and scans showed bleeding in his brain. Four days later, there was evidence of multiple strokes.

“Despite improving findings on cerebrospinal fluid testing and control of seizure activity, there was no meaningful neurologic recovery,” the report states. The man had suffered severe brain injury, and the family decided against aggressive treatment and he was taken off life support. The man died 22 days after his second hospital visit began.

In an accompanying review article, a separate group of doctors from Alabama, Texas, and Michigan describe how this first case sparked doctors around the country to realize that unusal cases they had seen and been puzzled by might be linked.

The unusual case of meningitis in Tennessee was “the trigger” for discovering the link to the patients’ recent epidural injections, the physicians wrote.

“Then events fell into place,” they wrote. “After the alarm was sounded about this association, other phsyicians throughout the country realized that they too had struggled to find a cause for similar cases in recent weeks.”

Carolyn Y. Johnson can be reached at cjohnson@globe.com. Follow her on Twitter @carolynyjohnson.
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