June 23, 2023
This health advisory is an update to the June 1 advisory on the same topic to reflect the latest guidance from the CDC. Updated portions of the advisory have been bolded in the Action Requested section below.
Action Requested
- Be aware that patients who underwent medical or surgical procedures under epidural anesthesia in Matamoros, Mexico, and who have developed signs or symptoms of possible meningitis (e.g., fever, headache, stiff neck, nausea, vomiting, photophobia, altered mental status) should promptly seek evaluation by a healthcare provider and convey that medical history.
- Officials identified two clinics associated with the outbreak: River Side Surgical Center and Clinica K-3.
- Evaluate all patients, including those without symptoms, who report procedures under epidural anesthesia at either clinic since January 1, 2023, for fungal meningitis.
- Diagnostic lumbar puncture (LP), unless contraindicated, is recommended as part of clinical evaluation of exposed patients regardless of symptoms.
- An MRI of the brain with and without contrast is recommended for all exposed patients with abnormal LP results to assess for meningeal enhancement, vasculitis, stenosis, hemorrhage, or ischemia; for exposed patients with back pain or paresthesia, MRI with and without contrast of the spine is recommended to assess for local infection or meningeal enhancement; MRI of the brain is not required for patients with normal LP test results.
- Asymptomatic patients with normal LP results should continue to monitor for symptoms for at least 4 weeks. Consider repeating the LP after 2 weeks to ensure infection has not developed; if the patient has new or persistent symptoms, an LP should be repeated.
- To date, most cases have reported symptom onset ranges from 3 days to 4 weeks after the date of exposure.
- An algorithm for diagnosis and management as well as treatment guidance are available and may be updated as additional information is available.
- Consider ordering bacterial and fungal cultures of CSF fluid, as well as serum and CSF levels of (1,3)-beta-D-glucan. Healthcare providers can consider ordering other diagnostic tests including serum and CSF Aspergillus galactomannan and fungal polymerase chain reaction (PCR) testing.
- If fungal meningitis is suspected, treatment should be initiated as soon as possible after obtaining CSF; treatment should not be withheld because of negative fungal culture or (1,3)-beta-D-glucan results. Consultation with an infectious disease specialist is recommended.
- Treatment should involve broad-spectrum antifungal medications that have adequate central nervous system penetration. Dual agent antifungal therapy can be considered and has been used in previous fungal meningitis outbreaks.
- Although vaccines are available to prevent certain types bacterial and viral meningitis, no vaccine is available to prevent fungal meningitis.
- Healthcare providers should immediately report suspected fungal meningitis cases in Snohomish County to the Snohomish County Health Department.
See full CDC outbreak page more information
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