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IMPORTANCE - Fungal meningitis due to injections of contaminated methylprednisolone acetate can present with vascular sequelae in immunocompetent individuals. This is particularly germane to neurologists because better recognition of the clinical characteristics of patients with fungal meningitis and ischemic stroke will provide more timely and efficient care.
OBSERVATIONS - In a case series, 3 patients presented to Vanderbilt University Medical Center in Nashville, Tennessee, with acute ischemic stroke and later received a diagnosis of fungal meningitis attributed to epidural injections of contaminated methylprednisolone. Of these 3 patients, 2 were women, and the mean age for all 3 was 75.3 years. Their medical records and imaging scans were reviewed. All 3 patients presented with acute ischemic strokes and had a history of epidural spinal injections of methylprednisolone for low back pain. All 3 patients had 1 or more traditional risk factors for stroke. There were differing vascular patterns of presentation: 2 patients presented with small-vessel (lacunar) infarctions, whereas 1 patient presented with a large-vessel infarct. Of these 3 patients, 2 died and underwent an autopsy, which revealed Exserohilum rostratum as the presumed cause of death. For 2 cases, fever and meningeal signs were absent at presentation.
CONCLUSIONS AND RELEVANCE - Patients with fungal meningitis may present with ischemic stroke detected on initial imaging scans. A definitive diagnosis should not delay early antifungal treatment.
Persistent neutrophilic meningitis presents a diagnostic challenge, because the differential diagnosis is broad and includes atypical infectious causes. We describe a case of persistent neutrophilic meningitis due to Aspergillus fumigatus in an immunocompetent man who had no evidence of sinopulmonary or cutaneous disease. An epidural glucocorticoid injection was identified as a potential route of entry for this organism into the central nervous system, and the case was reported to the state health department.
STUDY DESIGN - A prospective cohort study.
OBJECTIVE - To evaluate the effects of epidural steroid injections (ESIs) on blood glucose levels in patients with diabetes mellitus.
SUMMARY OF BACKGROUND DATA - ESIs are commonly used in the treatment of multiple spinal disorders. Corticosteroid injections have been evaluated in the total joints and hand literature showing systemic effects to diabetics.
METHODS - Diabetic patients who were scheduled for an ESI were given an opportunity to enroll in our IRB-approved study. We collected the patient's most recent hemoglobin A(1c) (hA(1c)) and then asked them to track their blood glucose numbers at least twice per day for 2 weeks prior to and after their ESIs.
RESULTS - We noted a statistically significant increase in blood glucose levels in diabetic patients (n = 30) after ESI. The mean blood glucose level prior to ESI was 160.18 ± 47.46, and, after ESI, it was 286.13 ± 111.11. This represents an average 125.96 ± 100.97 increase in blood glucose levels after injection. Using a nonlinear mixed effect model, the estimated half-life of this increase was 1.06 days (95% CI 0.80, 1.58), meaning that the patients were back within their normal standard deviation mean glucose levels within 2 days of injection. There was no association between observed glucose level change and preinjection hA(1c) levels or age (Spearman = 0.0326 and -0.1091 separately), indicating that there is no correlation between preinjection hA(1c) levels and systemic response to ESI.
CONCLUSION - ESIs were noted to cause a significant increase in the blood glucose levels in diabetics. There was no correlation between preinjection diabetic control, represented by hA(1c) levels, and postinjection response. Diabetics who are candidates for ESI should be counseled that a blood glucose increase may be apparent post intervention, but effects should not last longer than approximately 2 days.