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MRI Can Find ‘Time Bomb’ Fungal Infections

June 26, 2013
Written by: , Filed in: Musculoskeletal Radiology
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Contrast-enhanced MRI can detect hidden fungal infections in and near the spine resulting from contaminated methylprednisolone acetate (MPA) injections—even when the patient reports minimal or no symptoms.

Last September, the New England Compounding Center, a compounding pharmacy in Framingham, Massachusetts, recalled three lots of preservative-free MPA steroid implicated in a multistate outbreak of fungal meningitis and other infections. In October, the pharmacy expanded the recall to include all products produced in its Framingham facility.

Michigan has reported the most spinal and near-spinal infections. Anurag N. Malani, MD, spoke to Medscape Medical News about the situation all these months later:

The outbreak is no longer in the mainstream media, but we still need to be thinking about these patients because we know that these fungal infections can be indolent and can present long after receipt of contaminated injection.

Dr. Malani, of IHA Infectious Diseases Consultants in Ypsilanti, Michigan, and St. Joseph Mercy Ann Arbor Hospital in Ann Arbor, Michigan, is lead author of an article published last week in JAMA, The Journal of the American Medical Association. It details a study that looked at 172 patients who had received an injection of contaminated MPA but had not reported any adverse effects.

Contrast-enhanced MRI revealed abnormalities in or near the spine in 36 of the patients, or 21 percent. All but one met Centers for Disease Control and Prevention criteria for probable or confirmed fungal infection.

“It’s clear from this outbreak that clinical symptoms can be subtle,” Dr. Malani said. “Even the patients who did have worsening symptoms hadn’t presented for care. Part of the difficulty for this group of patients is that many of them have chronic pain, and it’s difficult to determine whether their change in pain is due to their chronic pain or whether they have an infection.”

JAMA editorial that accompanied the article said, “These findings suggest MRI of the injection site may be an effective screening procedure in some patients but should not be widely adopted, particularly for patients who received peripheral joint injections, given the much lower attack rate.”

It seems clear that patients who received injections from the highly contaminated lot (06292012@26) should definitely be screened.

“For patients who received spinal injections with steroids from an unknown lot number,” the editorial said, “MRI-based screening may be appropriate. Whether patients with normal initial MRI findings receive reimaging at a later date remains a difficult question in this evolving outbreak.”

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Related CME seminar (up to 13.5 AMA PRA Category 1 credits™): New Horizons in Musculoskeletal MRI

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