Fungal Meningitis Outbreak Associated with Procedures Performed under Epidural Anesthesia in Matamoros, Mexico

This page was last updated on 8/11/23. Updates will be made as new information becomes available.

Current Update

  • Updated Case Counts

Fungal meningitis is a rare, life-threatening fungal infection that causes swelling of the areas around the brain and spinal cord. People can get infected during medical procedures if all infection control practices are not followed.

Background

CDC, the Mexican Ministry of Health, and U.S. state and local health departments are responding to a multinational outbreak of fungal meningitis among people who had procedures under epidural anesthesia in Matamoros, Tamaulipas, Mexico. Officials identified two clinics associated with the outbreak: River Side Surgical Center and Clinica K-3. These clinics were closed on May 13, 2023. Anyone who had procedures under epidural anesthesia in these clinics from January 1 to May 13, 2023, is at risk for fungal meningitis. Learn what to do if you are at risk.

The Mexican Ministry of Health provided CDC a list of U.S. residents who had procedures at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023. Using this list, CDC and state and local health departments are trying to reach all people at risk but continue to face challenges. Some of the listed contact information is incorrect or incomplete and some at-risk persons have been identified who were not on the list.  These people are being reached through outreach efforts like media and social media and through family, friends, and other contacts found during public health investigations. Health departments are encouraged to continue to raise awareness. CDC’s social media toolkit for partners provides graphics, videos, and messaging in English and Spanish to help with these efforts.

Anyone who is at risk for fungal meningitis should go to the nearest emergency room right away to be tested. Testing is done by a lumbar puncture (LP), also called a spinal tap. People who are infected should begin antifungal treatment as soon as possible.

Information for People at Risk

If you had epidural anesthesia in Matamoros, Mexico, at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023:

If I am At Risk for Fungal Meningitis why do I need to go to the Emergency Room? You can have Fungal Meningitis and not have any symptoms or have mild symptoms at first. Severe illness can come on quickly. Early testing and treatment can be life saving.

If you or someone you know are at risk for fungal meningitis, learn more about what to expect for testing and treatment.

Early testing and treatment, especially before symptoms start or worsen, can save lives.

Symptoms of fungal meningitis include fever, headache, stiff neck, nausea, vomiting, sensitivity to light, and confusion. 

It can take weeks to months for symptoms to develop, and they may be very mild or absent at first. However, once symptoms start, they can quickly become severe and life-threatening. Early testing and treatment can save lives.

  • Go to the nearest emergency room as soon as possible to be evaluated for fungal meningitis, even if you do not currently have symptoms.
    • Some people without symptoms or with mild symptoms have tested positive for infection and started treatment. Receiving treatment early can prevent severe illness.
    • Fungal meningitis can start off mild and very quickly become a life-threatening illness.
    • Consider printing and sharing this web page to help make sure staff and healthcare providers are aware of the situation and recommended tests.
  • If you cannot go to an emergency room (for example, because it is too far away), consider calling your local health center or urgent care facility to see if they can do spinal taps. In most situations, the emergency room will be the best or only option for testing.
  • When you arrive, tell emergency room staff that you need to be evaluated for possible fungal meningitis. Tell them that you recently had epidural anesthesia at one of the clinics in Mexico involved in this outbreak.

Important Points

  • If you had epidural anesthesia in Matamoros, Mexico, at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023, you are at risk for fungal meningitis: Go to the nearest emergency room as soon as possible to be evaluated for fungal meningitis, even if you do not currently have symptoms.
  • Starting treatment right away if you are found to have fungal meningitis greatly increases the likelihood of survival.
  • Fungal meningitis infections are not contagious and are not spread from person to person.
  • Cancel any elective procedure that involves an epidural injection of an anesthetic in Matamoros, Mexico, until there is evidence that there is no longer a risk for infection at these clinics.
  • Share information about this outbreak and reach out to any friends or family members that may have had procedures at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023.

If you are at risk for fungal meningitis, go to the emergency room (ER) right away, even if you do not have symptoms. For more information about your first steps, what to expect when you get tested, and more, visit Information for Patients.

What to Expect

  • Healthcare providers will perform a spinal tap by inserting a needle into your lower back in a space around your spine to collect fluid for laboratory testing. This is recommended even if you do not currently have symptoms.
  • The fluid will be tested in a laboratory to determine if you have fungal meningitis.
  • If you test positive for infection: your healthcare team will treat you with antifungal medicines in the hospital. When you go home, you will need to take antifungal medicine for at least 3-6 months to completely cure the infection.
  • If you test negative for infection: It is possible to test negative during the early phases of infection. This is called a false negative. If you develop new or worsening symptoms, you should return to the emergency room as soon as possible.
    • Your healthcare provider may ask you to come back in 2 weeks to repeat the spinal tap.
    • Watch for symptoms for at least 30 days after the first spinal tap.

Information for Healthcare Providers

See Clinician Outreach and Communication Activity (COCA) webinar describing epidemiology, diagnostics, and treatment.

Healthcare providers should immediately report suspected fungal meningitis cases, including those possibly related to this outbreak, to their state or local health department. Find contact information for your jurisdictional HAI program coordinator.

Interim Recommendations for diagnosis and management of cases (with or without symptoms) of possible fungal meningitis associated with epidural anesthesia administered in Matamoros, Mexico:

These interim recommendations:

  • Provide detailed diagnostic and management recommendations for clinicians caring for patients who underwent a procedure under epidural anesthesia in the city of Matamoros.
  • Is based on the clinical experience and expert opinion of clinicians caring for patients during the current outbreak or during previous outbreaks of healthcare-associated fungal meningitis in Durango, Mexico, and the United States. It will be updated as additional information becomes available.
  • This assessment involves a lumbar puncture to collect cerebrospinal fluid (CSF) for diagnostic laboratory testing.

Testing Asymptomatic Patients

  • Performing the diagnostic assessments in the interim recommendations on all patients with potential exposure, regardless of symptoms, will provide the best chance of preventing widespread morbidity and mortality from this outbreak for the following reasons:
  1. The latency of symptom onset in some affected patients provides a window of opportunity to identify infection and begin treatment early enough to prevent severe or life-threatening illness:
    • Patients without symptoms or with mild symptoms have tested positive for infection.
    • Symptom onset ranges from 3 days to 4 weeks after the date of exposure among reported cases to date.
    • Fungal meningitis may progress rapidly once symptoms start, causing more severe and harder to treat illness.
  2. The potential of high case-fatality rates related to this illness:
    • The fungus implicated in this outbreak (Fusarium solani) was associated with a 50% case-fatality rate during a recent outbreak of healthcare-associated central nervous system infections in Durango, Mexico.
    • Antifungal susceptibility testing of a strain of Fusarium solani isolated from a U.S patient showed that the isolate is highly resistant.

Information for Health Departments

What should I expect if I go to the Emergency Room? When you arrive, tell staff that you need to be evaluated for possible fungal meningitis.  Your provider will perform a spinal tap to collect fluid for laboratory testing even if you do not have symptoms.  Image of a healthcare worker performing a spinal tap on a patient in an emergency room HHS CDC Logo

CDC’s social media toolkit provides downloadable graphics and sample messages for use on social media to help raise awareness.

Health Departments

    • CDC has notified states and local jurisdictions where any patients live who were listed by the Mexican Ministry of Health as potentially at risk.
      • Health departments are notifying patients and telling them to go to an emergency room for testing. CDC developed resources to assist with notifying hospitals and patient notification.
      • Health departments can email CDC at FungalOutbreak@cdc.gov for resources and additional support.
    • All health departments can help raise awareness about the outbreak to help reach more people who may be at risk and encourage them to take the recommended actions.
      • Some people at risk were not included in the original list used to notify patients. They have been found and contacted through public health investigation, outreach efforts, social media, and by family and friends as they learn about the outbreak.
      • For more information about medical tourism and risk mitigation, see CDC Yellow Book 2024: Medical Tourism or contact medicaltourism@cdc.gov.

U.S. Cases under Investigation, Case Counts, and Deaths as of 8/11/23

U.S. Cases under Investigation, Case Counts, and Deaths as of 8/11/23
Case Types Case Counts
Persons under investigation
(People with no symptoms1 or symptoms are unknown, spinal tap results pending or unknown)
151
Suspected cases
(Symptoms consistent with meningitis, spinal tap results pending or unknown)
9
Probable cases
(Spinal tap results suggest meningitis;2 fungus not isolated)
14
Confirmed cases
(Fungus detected from samples3)
10
Deaths4 12

1 Meningitis symptoms include fever, headache, stiff neck, nausea, vomiting, photophobia, and altered mental status.

2 Cerebrospinal fluid (CSF) profile with >5 WBCs/mm3, accounting for the presence of red cells (i.e., subtracting 1 white cell for every 500 RBCs present).

3 Fungus could be detected by culture, polymerase chain reaction (PCR) testing, or metagenomic next generation sequencing (mNGS) testing of CSF or tissue. Only select laboratories in the U.S. can test for the type of fungi involved in this outbreak creating a lag time between the spinal tap and receiving results.

4 Three probable cases and nine confirmed cases.

Findings and Investigations

Select key findings:

  • Elevated levels of Beta-d-glucan, a biomarker of fungal infection, have been detected in the CSF of some U.S. patients.
  • Three U.S. laboratories (CDC Mycotic Diseases Branch’s Laboratory, UCSF Clinical Microbiology Laboratory, and UW Medicine Molecular Microbiology Laboratory) and the Mexican national laboratory (InDRE) have detected fungal signals consistent with the Fusarium solani species complex from the CSF of patients receiving care in Mexico or the United States.
  • Antifungal susceptibility testing of a strain of Fusarium solani isolated from a U.S patient showed that the isolate is highly resistant.

Continuing investigations:

  • CDC and partners are investigating to determine how people were exposed to the infectious organism(s) during the procedures.
  • Officials are investigating whether any additional clinics were involved.

What CDC Is Doing

  • Published a Travel Health Notice
  • Distributed a Health Alert Notice (HAN) Health Advisory and HAN Health Advisory Update
  • Collaborated with the Mycoses Study Group to develop clinical resources: Interim Recommendations, a One-page Summary of Interim Recommendations, and an Algorithm for diagnosis and treatment.
  • Collaborated with the Mycoses Study Group to produce a webinar discussing epidemiology, diagnostics, and treatment
  • Held a Clinician Outreach and Communication Activity (COCA) webinardescribing Interim Recommendations describing epidemiology, diagnostics, and treatment.
  • Facilitating outreach to potentially impacted patients
  • Coordinating and performing specimen testing
  • Continuing to investigate the source of the outbreak with colleagues in Mexico
  • Disseminating information and strategic outreach to clinicians, the public, and partners
  • Providing technical, diagnostic, and clinical advice as requested

Original Article – https://www.cdc.gov/hai/outbreaks/meningitis-epidural-anesthesia.html

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