By Barbara Bronson Gray
TUESDAY, Oct. 16 (HealthDay News) -- The nationwide meningitis outbreak linked to contaminated steroid injections has so far been focused on back pain patients.
Far less attention has been paid to those patients who got injections of methylprednisolone acetate to ease chronic pain in joints such as knees, shoulders and hips.
The U.S. Centers for Disease Control and Prevention is now reporting that two people who received a steroid injection for pain in a joint -- rather than the back -- may have come down with a fungal infection.
One case is in Michigan, the other New Hampshire, but it will take time to confirm they are fungal infections, agency spokeswoman Melissa Dankel said Monday.
People with chronic pain in ankles, knees, shoulders, hips and thumbs commonly get injections of methylprednisolone acetate in the troubled joint to relieve inflammation that causes discomfort and limits movement.
Unlike the spinal injections that have been associated with meningitis -- an infection of the protective membranes of the brain and spinal cord -- any joint infections tied to the contaminated steroids aren't likely to be fatal, experts said.
But they can be risky, they added.
"Fungal infections in a joint can be extremely difficult to treat and can be quite devastating," said Dr. Sanjeev Suratwala, a spinal reconstructive surgeon at Glen Cove Hospital in Glen Cove, N.Y. "Typically, these patients need several months of antibiotics and are prone to relapses, and may even require surgical treatment."
Suratwala said that while the waiting period for meningitis in the spine or brain has been about one to four weeks, joint infections can take longer to appear. "Fungal infections can be masked, so it may take a longer time to present itself," he said.
And because joint injections are far more common than epidural injections to the spine, these first cases of infection in people who received the steroid for joint pain suggests many more patients could be at risk, Suratwala said.
As of Tuesday, the toll from the fungal meningitis outbreak stood at 15 dead and 231 people infected. All of the patients were thought to have been injected with methylprednisolone acetate manufactured at the New England Compounding Center, in Framingham, Mass. Health officials in the 23 states that received shipments of the drug have been able to contact about 11,000 patients so far, CDC officials said.
Methylprednisolone acetate is used to control joint pain for a variety of reasons, said Dr. Neil Roth, an orthopedic surgeon at Lenox Hill Hospital in New York City. "It's a widely available soluble type of cortisone that doesn't erode cartilage or tendons and gives a quick dosing effect."
Roth said he expects to see fungal infections particularly in people who had injections to the knee, because "the knee joint is the most common injection done in the orthopedic setting."
CDC officials said they've just released interim guidelines for doctors on how to treat fungal joint infections. They're also recommending that doctors treat people suspected of having fungal meningitis, even if tests initially come back negative, because the fungus linked to these infections -- called Exserohilum rostratum -- can be tough to identify.
The CDC recommends that patients who received joint injections with methylprednisolone acetate seek medical care if they have signs of infection, such as swelling, increasing pain, redness or warmth at the injection site.
Roth said people scheduled to get steroid injections for joint or back pain should ask their doctor where the steroid came from. He also suggested that patients find out whether their physician's office or clinic has been associated with any meningitis or fungal infections.
"As a patient, you have a right to know where the medication is coming from," he said.
Dr. John Tongue, president of the American Academy of Orthopaedic Surgeons and an orthopedist in Tualatin, Ore., said he wanted to highlight the safety of steroid injections for pain.
"I would hope this would not deter people from getting steroid injections to the joints," he said.
Tongue said millions of steroid injections into joints are done every year without infections. "It's kind of bread-and-butter orthopedics," he said.
He added that the American Academy of Orthopaedic Surgeons doesn't have a guideline or policy against using compounding pharmacies such as the one in Massachusetts. "This is a new issue to me. We'll have to look at it," he said.
Compounding pharmacies "combine, mix, or alter ingredients to create unique medications to meet specific needs of individual patients," according to the U.S. Food and Drug Administration. The customized drugs are frequently required to accommodate special cases, such as a smaller dose, or the removal of an ingredient that might cause an allergy in a patient. Sometimes compounding pharmacies also produce drugs when FDA-approved manufacturers are unable to meet demand, as during drug shortages, the agency said.
Also Monday, the FDA issued warnings about additional drugs produced by the Massachusetts company.
The agency said it was investigating a report of a meningitis infection in a patient who got a different steroid than the one linked to the nationwide infections.
The FDA also said it was checking reports of fungal infection in a heart transplant patient who got a cardiac solution made by the New England Compounding Center. The solution is used to paralyze heart muscle to prevent injury to the heart. It's possible, however, that the infection came from a source other than the solution, the agency said.
The CDC has more on the meningitis outbreak.
SOURCES: Sanjeev Suratwala, M.D., spinal reconstructive surgeon, Glen Cove Hospital, Glen Cove, N.Y.; Neil Roth, M.D., orthopedic surgeon and sports medicine specialist, Lenox Hill Hospital, New York City; John Tongue, M.D., president, American Academy of Orthopaedic Surgeons, adjunct clinical associate professor, Oregon Health & Science University, Portland, Ore.; Melissa Dankel, spokeswoman, U.S. Centers for Disease Control and Prevention
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