The appropriate bedside medical response related to the ongoing fungal meningitis epidemic is becoming increasingly complex. As we know, officials have identified steroid vials, contaminated with fungi, that are causing meningitis, strokes, and death in patients who received epidural or paraspinal injections. The greatest risk of illness is within 42 days of exposure. If the exposed person becomes symptomatic, diagnostic evaluation and treatment are fairly straightforward. But the question centers around what to do about the asymptomatic patient who has been exposed and could be incubating illness.
CDC issued new guidance this morning with two options for persons within the 42 day period since last exposure. Option 1 maintains the current strategy: closely monitor the exposed person for the development of symptoms and conduct a lumbar puncture if he/she becomes symptomatic. Option 2: conduct a lumbar puncture on an asymptomatic person. If the lumbar puncture reveals greater than 5 WBCs in CSF, the person should be treated for fungal meningitis. If the lumbar puncture shows less than 5 WBCs in CSF, the person should be followed very closely for symptom onset and physicians should consider weekly lumbar punctures until 42 days have passed since the last exposure to potentially contaminated steroid product. CDC estimates that Option 2 could reduce the maximal risk of stroke or death from approximately 0.4% to 0.3% in comparison to Option 1.
Lumbar punctures are not risk-free and pose their own set of concerns. Moreover, we are now more than halfway into the 42 day incubation period (since product was removed from medical shelves) and the risk of serious complications diminishes with time. Resolving this dilemma at the bedside involves as assessment of the current epidemiologic information, its relevance to an individual patient, and a discussion with exposed patients about the benefits and risks of either option to gain their perspectives about the desired course of action.