Updated, Oct. 6: Federal health officials have widened their recall of drugs suspected of giving people an unusual type of meningitis that has so far killed seven, and identified two different types of fungus they believe are infecting people.

At least 64 cases in nine states have been diagnosed with meningitis linked to the contaminated drugs, the Centers for Disease Control and Prevention reported Saturday.

Health experts expect more cases will be reported and are asking anyone who had a recent steroid injection for lower back pain to be on the lookout for headaches, stiff necks, unsteadiness and other classic symptoms of meningitis.

“All patients who may have received these medications need to be tracked down immediately. Patients can find the names of the clinics that used these medications on the CDC website,” said CDC's Dr. Benjamin Park, medical officer for the fungal diseases branch. “It is possible that if patients with infection are identified soon and put on appropriate antifungal therapy, lives may be saved.”

Tennessee state health officials said four more people had been diagnosed there since Thursday, bringing that state’s total cases to 29, with three deaths. Michigan is the latest to report cases, with four there. People with suspected fungal meningitis have been diagnosed in Tennessee, Virginia, Maryland, Florida, North Carolina, Michigan and Indiana.

The drug is question is called methylprednisone and is used mostly to treat older patients for lower back pain. All the cases so far have been traced to a single pharmacy in Massachusetts that makes the drugs to order. The pharmacy has closed, surrendered its license and recalled its products, Food and Drug Administration officials said. But they said hundreds of people could have been injected with contaminated steroids and possibly other products. The pharmacy could have shipped products to all 50 states.

CDC listed the 75 clinics known to have received shipments of methylprednisolone from the pharmacy.

Tennessee Health Commissioner Dr. John Dreyzehner said the clinics that treated the patients are not to blame. “Our continuing investigation found no lapses in process at the clinics,” Dreyzehner told reporters Friday. “Evidence indicates these clinics and clinicans had no way of knowing about the contamination.”

"Fungus has been identified in specimens obtained from 9 patients, including Aspergillus and Exserohilum," CDC said. Both types of fungus are found in back yards --  Exserohilum can cause leaf spot but it's also been linked to skin and sinus infections. Aspergillus causes lung infections in cancer, HIV and other patients with suppressed immune systems.

Some kind of fungal contaminant has been found in at least one vial of drugs made by the pharmacy. Fungi can grow in drugs that are not stored properly, especially those without preservatives, like those made by the compounding pharmacy.

Meningitis is an inflammation of the spinal cord, usually caused by bacteria or viruses. It can be very serious and symptoms include headache, fever, often a stiff neck and balance problems. Fungi and parasites can also cause this inflammation and in this case the common mold aspergillus is suspected.

Fungal infections are tricky to treat. Antifungal drugs including voriconazole and amphotericin can be used to treat the infections.

"Currently, we think that this type of meningitis is quite severe as we have been describing here. The antifungal treatment for this is intravenous antifungal treatment and requires initial hospitalization. But the duration of antifungal therapy could be prolonged, possibly on the order of months," Park said.

To be especially careful, health officials have widened their warning to anyone who got a steroid injection in the spine between July 1 and September 28 this year. “Infected patients have presented approximately 1 to 4 weeks following their injection with a variety of symptoms, including fever, new or worsening headache, nausea, and new neurological deficit (consistent with deep brain stroke),” the FDA said in a statement on its website.

“Some of these patients’ symptoms were very mild in nature.”

The FDA says there will be no shortage of methylprednisone. “There are FDA approved versions of methylprednisolone acetate injection on the market, available with or without preservatives,” it said.

“Although all cases detected to date occurred after injections with products from these three lots, out of an abundance of caution, CDC and FDA recommend that healthcare professionals cease use of any product produced by the New England Compounding Center until further information is available,” the FDA added. Among the other drugs from the pharmacy being recalled are three steroid drugs -- betamethasone, a steroid usually given in creams or as a spray, dexamethasone and triamcinolone; two local anesthetics called lidocaine and bupivicaine; the blood pressure drug clonidine; and saline.

Compounding pharmacies are not regulated as closely as drug manufacturers, and their products are not subject to FDA approval.

Centers for Disease Control and Prevention

List of healthcare facilities that received large amounts of methylprednisolone acetate (PF) recalled from New England Compounding Center on Sept, 26, 2012.

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Courtesy Centers for Disease Control and Prevention

The fungus aspergillus is suspected in four deaths and 26 cases.

Four people have died and 22 were made sick by meningitis linked to a rare fungal infection blamed on contaminated steroids, health officials said on Wednesday. They are “almost certain” more will be identified before it’s over.

The 26 cases include 18 people in Tennessee, one in North Carolina, two in Florida, three in Virginia and two in Maryland, the U.S. Centers for Disease Control and Prevention reported. Two of the deaths were in Tennessee, one in Virginia and one in Maryland.

Several of the patients are seriously ill, says Tennessee Department of Health Commissioner Dr. John Dreyzehner. Two clinics have closed voluntarily and a third is no longer giving the injections.

Officials said the chief suspect is contaminated vials of a pain treatment injected directly into the spine. The drug is called methylprednisolone acetate.

“We have notified medical professionals the prime suspect for this outbreak is methylprednisolone,” Dreyzehner told reporters in a telephone briefing. He said it was not yet clear how widely the drug was distributed.

Late Wednesday, the Food and Drug Administration confirmed that New England Compounding Center, a Framingham, Mass., compounding pharmacy, on Sept. 26 voluntarily recalled three lots of 80-milligram injection doses of methylprednisolone acetate (PF) produced by the firm. The lots included #05212012@68 with a had beyond use date of Nov. 17, 2012; #06292012@26 with a beyond use date of Dec. 26, 2012; and #08102012@51 with a beyond use date of Feb. 6, 2013. The firm's website was not working on Wednesday evening.

It’s not entirely certain the steroid is to blame, said the health department’s Dr. Marion Kainer. The health officials, the CDC and the FDA are testing the pain medications and other materials used with the steroid injections, as well as samples from the patients. Patients were also treated with injections of lidocaine and a povidone iodine skin preparation solution, the CDC said. 

Meningitis is an inflammation of the spinal cord, usually caused by bacteria or viruses. It can be very serious and is marked by a headache, fever, often a stiff neck and balance problems. Fungi and parasites can also cause this inflammation and in this case the common mold aspergillus is suspected. “The type of meningitis we are dealing with in this situation is not communicable person to person,” Dreyzehner said.

The 18 Tennessee cases are associated with Tennessee centers: Saint Thomas Outpatient Neurosurgery Center in Nashville, a center in Crossville, and now a third center in Oak Ridge, the officials said. The cases were all injected from two lots of steroids. 

Everyone treated at the centers since July 1 is being cautioned to look for symptoms and to see a doctor immediately if they develop any. More than 700 people were treated, Dreyzehner said. “Everybody who been exposed to the lot numbers that are suspect, the vast majority have not been symptomatic,” he said.

The incubation period -- the time between treatment and the first symptoms-- ranges from two days to two months, the officials said. No one treated before July 30 has turned up sick but they said they were checking people back to July 1 out of an abundance of caution. The first 12 patients who were identified range in age from 49 to 89.

The CDC and FDA are testing samples of the drug, which has been recalled nationwide, as well as samples from the patients to be sure it’s aspergillus. Aspergillus has not been isolated yet from the steroid.

Aspergillus is tricky to treat. It’s an infection that patients with damaged immune systems can get – notably cancer patients and those with HIV infection. It’s often found in the lungs because the mold – found in dead leaves and elsewhere -- can be breathed in. An antifungal drug called voriconazole can treat the infection but the health officials said in this case they want to be sure before they try it. The side effects from the antifungal treatment can be severe and include kidney and liver damage.

It's also hard to reach an infection in the spinal cord.

The health officials stress that women who got epidural injections while giving birth are not at risk in this outbreak. In 2005, after a giant quake and tsunami devastated shorelines around the Indian Ocean, a team of doctors in Sri Lanka reported on an outbreak of aspergillus meningitis among women who got epidurals during childbirth. Five young women were infected and three of them died.

In that case, they reported in several medical journals, the anesthetics used had been stored in hot and dirty warehouses in the aftermath of the tsunami’s devastation.

Related links:

• Fungus meningitis sickens 12, kills 2
• Parents of killed toddler settle tainted wipes lawsuit

As cases of West Nile virus continue to mount in what may be record numbers, government health officials are urging people -- particularly those in the worst-affected states -- to cover up, use insecticide and remove the standing water that helps fuel the mosquito-borne infections.

Cases of West Nile virus in the U.S. are about three times higher than normal for this time of year, officials with the Centers for Disease Control and Prevention said Tuesday, with at least 1,118 illnesses in what's being described as one of the worst outbreaks since the virus was detected here in 1999.

About half of the cases have been in Texas, where drought and heat, followed by rain, have contributed to the outbreak that has killed 19 people in that state. Forty-one have died nationwide, CDC says.

In normal years, fewer than 300 cases are reported in the U.S. by mid-August, with most illnesses typically reported in late August and September. It's difficult to tell how this season will progress, officials said.

CDC

Pesky mosquitoes are behind one of the worst-ever outbreaks of West Nile virus, health officials say.

A handful of states have seen the most infections, including Texas, Louisiana, Mississippi, Oklahoma, South Dakota and California -- but the virus can occur anywhere, CDC officials said.

West Nile virus, which is most often spread through the bites of infected mosquitoes, usually isn’t deadly. Only about 20 percent of infected people even realize they have it. Those who do develop symptoms of West Nile fever typically complain of headache, fever, tiredness and, sometimes, a rash.

But 1 percent of cases develop into severe disease, usually meningitis, an inflammation of the spinal cord.  They may die quickly or result in nerve damage.

The severe cases usually strike the elderly and those with impaired immune systems, but it’s important to prevent West Nile infection when possible.

Here are CDC’s top tips for avoiding West Nile virus.

• Use insect repellents that contain an EPA-registered active ingredient whenever you’re outdoors.
• Wear long-sleeved shirts and long pants outdoors at dawn and dusk, or consider staying indoors during those times, when mosquitoes are most active.
• Install or repair screens on windows and doors to keep mosquitoes out.
• Remove the standing water that allows mosquitoes to breed. That includes small pools of water in unlikely places such as flower pots, buckets and barrels. Change the water in pet dishes and replace the water in bird baths weekly.
• Drill holes in tire swings so that water drains out. Keep children’s wading pools empty and on their sides when they’re not being used.

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