Iatrogenic Fungal Infections of Central Nervous System

Iatrogenic fungal infections of the central nervous system had been considered a medical curiosity. Generally, they are a rare isolated complication of neurosurgical procedures, but periodically these infections are observed in larger populations as a result of exposure to contaminated materials during diagnostic or therapeutic procedures. In the last year, an epidemic of iatrogenic fungal central nervous system disease accompanied the use of fungal-contaminated compounded methylprednisolone distributed by one facility, heightening the attention given to this infectious disorder. As of May 6, 2013, 758 individuals from 20 US states have developed meningitis and/or spinal or paraspinal infection because of contaminated methylprednisolone from the New England Compounding Center in Framingham, Massachusetts, and 58 deaths have been reported. A total of 12 different fungi have been identified; Exserohilum rostratum, a filamentous environmental fungus rarely associated with human disease previously, has been the most commonly isolated pathogen. Meningitis has dominated the clinical presentation, accounting for more than half of the cases, but spinal and paraspinal infections, arachnoiditis, and stroke have also been observed. The diagnosis can be challenging as the organisms may be fastidious. An assay for β-d-glycan has been proposed as an effective adjunctive test for E. rostratum infection. The current therapeutic recommendation is a 6 mg/kg dose of voriconazole every 12 h followed by liposomal amphotericin B. In some instances, surgical debridement and drainage may be necessary.