Iatrogenic Exserohilum infection of the central nervous system

Mycological identification and histopathological findings

W. Robert Bell, Justin B. Dalton, Chad M. McCall, Sarah Karram, David T. Pearce, Warda Memon, Richard Lee, Karen C. Carroll, Jennifer L. Lyons, Elakkat D. Gireesh, Julie B. Trivedi, Deanna Cettomai, Bryan R. Smith, Tiffany Chang, Laura Tochen, John N. Ratchford, Daniel M. Harrison, Lyle W. Ostrow, Robert D. Stevens, Li Chen & 1 others Sean X. Zhang

Research output: Contribution to journalArticle

20 Citations (Scopus)

Abstract

An outbreak of fungal infections has been identified in patients who received epidural injections of methylprednisolone acetate that was contaminated with environmental molds. In this report, we present the mycological and histopathological findings in an index case of Exserohilum meningitis and vasculitis in an immunocompetent patient, who received a cervical spine epidural steroid injection for chronic neck pain 1 week before the onset of fulminant meningitis with subsequent multiple brain and spinal cord infarcts. The fungus was recovered from two separate cerebrospinal fluid specimens collected before initiation of antifungal therapy and at autopsy on standard bacterial and fungal culture media. The mold was identified phenotypically as Exserohilum species. DNA sequencing targeting the internal transcribed spacer region and D1/D2 region of 28S ribosomal DNA enabled further speciation as E. rostratum. Gross examination at autopsy revealed moderate brain edema with bilateral uncal herniation and a ventriculostomy tract to the third ventricle. The brainstem, cerebellum, and right orbitofrontal cortex were soft and friable, along with hemorrhages in the cerebellar vermis and thalamus. Microscopic examination demonstrated numerous fungi with septate hyphae invading blood vessel walls and inducing acute necrotizing inflammation. The leptomeninges were diffusely infiltrated by mixed inflammatory cells along with scattered foci of fungal elements. This is the first report of iatrogenic E. rostratum meningitis in humans. This report describes the microbiological procedures and histopathological features for the identification of E. rostratum (a pigmented vascularly invasive fungi), the cause of a current nationwide outbreak of fatal fungal meningitis.

Original languageEnglish (US)
Pages (from-to)166-170
Number of pages5
JournalModern Pathology
Volume26
Issue number2
DOIs
StatePublished - Feb 1 2013

Fingerprint

Central Nervous System Infections
Fungi
Meningitis
Epidural Injections
Disease Outbreaks
Autopsy
Fungal Meningitis
Ventriculostomy
Third Ventricle
Hyphae
Mycoses
Neck Pain
Brain Edema
Vasculitis
Ribosomal DNA
Prefrontal Cortex
Thalamus
DNA Sequence Analysis
Chronic Pain
Cerebellum

Keywords

  • epidural steroids
  • Exserohilum rostratum
  • Fungal meningitis
  • methylprednisolone
  • outbreak
  • vasculitis

ASJC Scopus subject areas

  • Pathology and Forensic Medicine

Cite this

Robert Bell, W., Dalton, J. B., McCall, C. M., Karram, S., Pearce, D. T., Memon, W., ... Zhang, S. X. (2013). Iatrogenic Exserohilum infection of the central nervous system: Mycological identification and histopathological findings. Modern Pathology, 26(2), 166-170. https://doi.org/10.1038/modpathol.2012.208

Iatrogenic Exserohilum infection of the central nervous system : Mycological identification and histopathological findings. / Robert Bell, W.; Dalton, Justin B.; McCall, Chad M.; Karram, Sarah; Pearce, David T.; Memon, Warda; Lee, Richard; Carroll, Karen C.; Lyons, Jennifer L.; Gireesh, Elakkat D.; Trivedi, Julie B.; Cettomai, Deanna; Smith, Bryan R.; Chang, Tiffany; Tochen, Laura; Ratchford, John N.; Harrison, Daniel M.; Ostrow, Lyle W.; Stevens, Robert D.; Chen, Li; Zhang, Sean X.

In: Modern Pathology, Vol. 26, No. 2, 01.02.2013, p. 166-170.

Research output: Contribution to journalArticle

Robert Bell, W, Dalton, JB, McCall, CM, Karram, S, Pearce, DT, Memon, W, Lee, R, Carroll, KC, Lyons, JL, Gireesh, ED, Trivedi, JB, Cettomai, D, Smith, BR, Chang, T, Tochen, L, Ratchford, JN, Harrison, DM, Ostrow, LW, Stevens, RD, Chen, L & Zhang, SX 2013, 'Iatrogenic Exserohilum infection of the central nervous system: Mycological identification and histopathological findings', Modern Pathology, vol. 26, no. 2, pp. 166-170. https://doi.org/10.1038/modpathol.2012.208
Robert Bell, W. ; Dalton, Justin B. ; McCall, Chad M. ; Karram, Sarah ; Pearce, David T. ; Memon, Warda ; Lee, Richard ; Carroll, Karen C. ; Lyons, Jennifer L. ; Gireesh, Elakkat D. ; Trivedi, Julie B. ; Cettomai, Deanna ; Smith, Bryan R. ; Chang, Tiffany ; Tochen, Laura ; Ratchford, John N. ; Harrison, Daniel M. ; Ostrow, Lyle W. ; Stevens, Robert D. ; Chen, Li ; Zhang, Sean X. / Iatrogenic Exserohilum infection of the central nervous system : Mycological identification and histopathological findings. In: Modern Pathology. 2013 ; Vol. 26, No. 2. pp. 166-170.
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