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Case Report/Case Series |

Vascular Complications of Fungal Meningitis Attributed to Injections of Contaminated Methylprednisolone Acetate

Kirk Kleinfeld, MD1; Pearl Jones, MD1; Derek Riebau, MD1; Ariana Beck, MD1; Paisit Paueksakon, MD1; Ty Abel, MD, PhD1; Daniel O. Claassen, MD, MS1
[+] Author Affiliations
1Departments of Neurology, Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
JAMA Neurol. 2013;70(9):1173-1176. doi:10.1001/jamaneurol.2013.3586.
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Importance  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.

Observations  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 and Relevance  Patients with fungal meningitis may present with ischemic stroke detected on initial imaging scans. A definitive diagnosis should not delay early antifungal treatment.

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Figure 1.
Magnetic Resonance Imaging (MRI) Findings for 3 Cases

For case 1, on hospital day 1, a diffusion-weighted imaging (DWI) scan reveals an acute upper pontine/lower midbrain ischemic stroke suggestive of a small-vessel etiology (A); on hospital day 3, another MRI scan reveals the direct extension of stroke into the right thalamus, suggestive of a large-vessel etiology (B); and on hospital day 4, a computed tomographic angiography scan reveals an occlusion of the right superior cerebellar artery (C). For case 2, on hospital day 1, a DWI scan reveals acute left pontine and cerebellar ischemic strokes suggestive of a large-vessel etiology (D); on hospital day 15, a T1-weighted sequence with contrast reveals an abscess adjacent to the left cerebellopontine angle (E); and on hospital day 15, a lumbar MRI T1-weighted sequence with contrast reveals extradural enhancement and clumping of nerve roots suggesting arachnoiditis (F). For case 3, on hospital day 1, a DWI scan reveals a right small-vessel internal capsule stroke (G); on hospital day 7, a DWI scan reveals a right internal capsule and a left internal capsule genu stroke (H); and on hospital day 7, a T1-weighted sequence with contrast also reveals a left-sided cerebellopontine abscess (I).

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Figure 2.
Pathology Findings

Hematoxylin-eosin stain of mycotic aneurysm of the left superior cerebellar artery (A [original magnification ×4]), higher-power view of Gomori methenamine silver stain of hyphal elements within the mycotic aneurysm of the superior cerebellar artery (B [original magnification ×40]), and gross photograph of mycotic aneurysm of the left superior cerebellar artery (C).

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