by Chris Kaiser
Cardiology Editor, MedPage Today
There should be a “high index of suspicion for possible fungal meningitis” when ischemic stroke occurs in the posterior circulation and patients have a history of epidural spinal injections, according to researchers who reported a small series of case studies.
In these three cases, one patient experienced a stroke a full month after an epidural injection of contaminated methylprednisolone, and the other two presented with stroke 2 weeks post injection, senior author Daniel O. Claassen, MD, MS, a neurologist at Vanderbilt University in Nashville, told MedPage Today.
But even longer incubation periods have been reported by the CDC and others, said Claassen, whose study was published this week in JAMA Neurology.
In the current case studies, the infarcts were primarily located in the cerebellum and/or brain stem, he said.
Last year, a compounding pharmacy in Massachusetts distributed contaminated methylprednisolone, leading to numerous deaths from fungal meningitis.
“We are finding all sorts of new presentations of fungal infections of the central nervous system,” Luis Ostrosky, MD, a professor in the division of infectious diseases at the University of Texas Health Science Center at Houston, told MedPage Today.
“This particular fungus is angiotropic, which means it likes blood vessels. We think it is traveling and creating an inflammatory reaction in blood vessels. That’s why we are seeing presentations of stroke,” said Ostrosky, who was not involved in the study.
Two patients had small-vessel infarcts, while one presented with a large-vessel infarct. The infarcts were fed by basilar, superior cerebellar, and posterior cerebral artery branches.
The infection can have an incubation period of 1 to 4 weeks between the last spinal injection and when a patient seeks medical care, and it can present in different ways, researchers noted.
The early MRI scans showed signs of a classic ischemic stroke, and all three patients had at least one or more traditional stroke risk factors.
Presenting with stroke is “not completely atypical for this disease,” Claassen noted, but the rate is not “abnormally high.”
Early in suspected cases of infection, a screening MRI may provide early warning of spinal or paraspinal meningitis, one study reported.
In the first case study, a 78-year-old man presented with acute onset of left-sided weakness and speech disorder. He had no meningeal signs at the time.
On day three and thereafter, the MRI scans showed infarct expansion, and the patient’s left-sided weakness increased. He died on the sixth day. An autopsy showed fungal cerebral vasculitis andExserohilum species were found microscopically.
The second case involved a 78-year-old woman who presented with complaints of headache, vertigo, and nausea. She had mild ataxia and MRI scans revealed ischemic infarcts in the posterior circulation, one suggestive of a large-vessel infarct, but stenosis was ruled out on CT angiography.
On day four, she developed fever, and neurologists noted mild encephalopathy. MRI revealed a new infarct and her health continued to deteriorate. Because of her history of epidural injections and, at the time, recent reports of fungal meningitis, researchers performed a lumbar puncture and results suggested the need for antibiotics.
She died 50 days after presentation and an autopsy revealed hyphal fungal forms in the arterial wall that researchers believed represented Exserohilumspecies based on CDC studies.
Case 3, a 70-year-old woman, began with headaches, fever, and balance difficulty. Her history revealed an epidural spinal injection 1 month prior. MRI showed small-vessel ischemic strokes, but MR angiography did not reveal any significant stenoses.
Again, concerned for meningitis led to a lumbar puncture and based on results, antibiotics were started. She was discharged 37 days later.
“These cases highlight a diagnostic dilemma for neurologists. Patients with fungal meningitis who present with ischemic strokes may be afebrile, lack signs of meningeal irritation, and have traditional stroke risk factors,” Claassen and colleagues said.
“An awareness of the presentation and vascular sequelae of fungal meningitis in immunocompetent patients should lead to earlier treatment and improved outcomes prior to a definitive diagnosis,” they concluded.
From the American Heart Association:
None of the authors had conflicts of interest to report.
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