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Exserohilum infections associated with contaminated steroid injections: a clinicopathologic review of 40 cases Ritter JM; Muehlenbachs A; Blau DM; Paddock CD; Shieh WJ; Drew CP; Batten BC; Bartlett JH; Metcalfe MG; Pham CD; Lockhart SR; Patel M; Liu L; Jones TL; Greer PW; Montague JL; White E; Rollin DC; Seales C; Stewart D; Deming MV; Brandt ME; Zaki SRAm J Pathol 2013[Sep]; 183 (3): 881-92September 2012 marked the beginning of the largest reported outbreak of infections associated with epidural and intra-articular injections. Contamination of methylprednisolone acetate with the black mold, Exserohilum rostratum, was the primary cause of the outbreak, with >13,000 persons exposed to the potentially contaminated drug, 741 confirmed drug-related infections, and 55 deaths. Fatal meningitis and localized epidural, paraspinal, and peripheral joint infections occurred. Tissues from 40 laboratory-confirmed cases representing these various clinical entities were evaluated by histopathological analysis, special stains, and IHC to characterize the pathological features and investigate the pathogenesis of infection, and to evaluate methods for detection of Exserohilum in formalin-fixed, paraffin-embedded (FFPE) tissues. Fatal cases had necrosuppurative to granulomatous meningitis and vasculitis, with thrombi and abundant angioinvasive fungi, with extensive involvement of the basilar arterial circulation of the brain. IHC was a highly sensitive method for detection of fungus in FFPE tissues, demonstrating both hyphal forms and granular fungal antigens, and PCR identified Exserohilum in FFPE and fresh tissues. Our findings suggest a pathogenesis for meningitis involving fungal penetration into the cerebrospinal fluid at the injection site, with transport through cerebrospinal fluid to the basal cisterns and subsequent invasion of the basilar arteries. Further studies are needed to characterize Exserohilum and investigate the potential effects of underlying host factors and steroid administration on the pathogenesis of infection.|*Drug Contamination[MESH]|Adult[MESH]|Aged[MESH]|Aged, 80 and over[MESH]|Ascomycota/cytology/*physiology/ultrastructure[MESH]|Female[MESH]|Humans[MESH]|Immunohistochemistry[MESH]|Injections, Epidural[MESH]|Male[MESH]|Meningitis/microbiology/pathology[MESH]|Methylprednisolone Acetate[MESH]|Methylprednisolone/administration & dosage/adverse effects/*analogs & derivatives[MESH]|Middle Aged[MESH]|Mycoses/epidemiology/*etiology/microbiology/*pathology[MESH]|Polymerase Chain Reaction[MESH]|Steroids/*administration & dosage/adverse effects[MESH]|United States/epidemiology[MESH] |
