Health Alert: Outbreak of Fungal Meningitis

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Health Alert
May 23, 2023

Summary:

The Texas Department of State Health Services (DSHS), the Centers for Disease Control and Prevention (CDC), and local public health departments are investigating an outbreak of fungal meningitis among patients hospitalized in Texas after undergoing surgical procedures under epidural anesthesia in Matamoros, Mexico. This is an evolving situation and public health authorities are actively working to determine the source organism(s) causing the outbreak and the routes of exposure.

DSHS is issuing this Health Alert to ask Texas healthcare providers to consider fungal meningitis in the differential diagnosis for people who:

  • Traveled to Matamoros, Mexico, in 2023 to undergo a medical or surgical procedure involving epidural anesthesia, and who have developed headache and any of the following symptoms consistent with fungal meningitis:
    • Fever ≥101°F (38.3°C)
    • Stiff neck
    • Nausea/vomiting
    • Photophobia (sensitivity to light)
    • Confusion, disorientation, or another form of altered mental status

These individuals should promptly seek evaluation by a healthcare provider.

Background:

The organism causing the outbreak is currently unknown, but current clinical findings suggest the infection is fungal. Affected patients underwent procedures in at least two clinics in Matamoros, Mexico, including River Side Surgical Center and Clinica K-3. Additional clinics may be identified as the investigation proceeds.

As of this health alert’s issuance, the outbreak includes seven cases among Texas residents. Seven patients were hospitalized, and one has died. Cases range in age from late 20s to early 50s, and all are female.

Recommendations for Healthcare Providers:

Healthcare providers should consider fungal meningitis in the differential diagnosis for patients who traveled to Matamoros, Mexico, in 2023 for a medical or surgical procedure involving epidural anesthesia and who have clinically compatible symptoms.

Healthcare providers should immediately consult with their local health department if they suspect their patient has fungal meningitis (Texas Local Public Health Contacts). If unable to make contact, please email HAIOutbreak@dshs.texas.gov.

Testing

Healthcare providers should consider the following diagnostic tests:

  • Brain imaging, ideally an MRI with and without contrast
  • Lumbar puncture (unless contraindicated)
  • Bacterial and fungal culture of cerebral spinal fluid (CSF)
  • Serum and CSF levels of (1,3)-beta-D-glucan
  • Serum and CSF Aspergillus galactomannan
  • CSF and/or tissue for pan-fungal polymerase chain reaction (PCR) testing; the following labs provide fungal PCR testing:
    • CLIA-approved pan-fungal PCR testing: this is available through the University of Washington (email: molmicdx@uw.edu; phone: (206) 685-6066 or (800) 713-5198)
    • CLIA-approved metagenomic testing that can detect fungal CSF pathogens (including fungus) is available through the University of California – San Francisco (Center for Next-Gen Precision Diagnostics)
    • CDC Laboratory
      • CSF and/or tissue from deceased individuals

Treatment

If fungal meningitis is suspected, treatment should be initiated as soon as possible after obtaining CSF. Treatment should not be withheld because of negative fungal culture or (1,3)-beta-D-glucan results.

DSHS recommends consultation with an infectious disease specialist while caring for a patient with suspected fungal meningitis. Providers who do not have access to infectious disease consultation or require additional expertise in management of fungal meningitis can email HAIOutbreak@dshs.texas.gov, and DSHS will help identify a provider specializing in treatment of fungal infections to provide consultation.

Treatment should involve broad-spectrum antifungal medications that have adequate central nervous system penetration. Dual agent antifungal therapy can be considered and has been used in previous fungal meningitis outbreaks.

Recommendations for the Public:

The CDC recommends that people who underwent surgery, including liposuction, with an epidural injection in Matamoros, Mexico in 2023 seek medical care immediately to be evaluated for a fungal infection. This includes people who are not sick and those who are feeling ill, including those with symptoms of meningitis (fever, headache, stiff neck, nausea, vomiting, sensitivity to light, and confusion).

People should consider canceling or postponing any elective procedure that involves an epidural, an injection of anesthetic in the area around the spine, in Matamoros until there is evidence that those procedures do not pose a significant risk of infection.

For More Information:

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