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October 13. 2012 8:00PM

4 in NH treated for fungal meningitis

Four New Hampshire residents have started treatment for fungal meningitis, the disease caused by tainted medication allegedly produced by a Massachusetts laboratory, state public health officials confirmed Saturday.

The four are considered likely to have contracted the disease, but diagnosing the illness is still considered inexact, according to Dr. Jose Montero, the state public health director.

Three of those tentatively diagnosed are men and one is a woman, three are in their 40s and one is older than 60, Montero said.

One of the people diagnosed has been released from a hospital, and another was awaiting discharge last night. Two others remained hospitalized.

The latest bulletin from the federal Centers for Disease Control and Prevention said 198 cases of fungal meningitis have been identified in 13 states.

There are 15 deaths attributed to the meningitis, the most recent in Indiana, which has now recorded two deaths.

Like others in affected states, the New Hampshire patients all had received the injection of preservative-free methylprednisolone acetate. The drug is given to treat back or joint pain.

PainCare LLC, a Somersworth-based practice, is the only medical provider in the state known to have used the drug.

Dr. Michael O'Connell, PainCare's chief executive, said reports so far on the patients tentatively diagnosed is positive.

“My understanding is that none are in danger, it does not appear to be life-threatening,” O'Connell said.

Making a complete and final diagnosis of fungal meningitis has been difficult, Montero said, because the symptoms may be the same as underlying conditions that resulted in people receiving the steroid injection in the first place.

“We have four people who meet the current definition,” Montero said. “One of the big complexities of this, particularly at the national level, is who do we call a (positive) case given the fact that the disease we are looking for seldom occurs in the population.”

Treatment for fungal meningitis is “complicated, expensive, time-consuming and harsh,” according to O'Connell, who said the ordeal of being treated makes inexact diagnoses all the more frustrating.

“We have been told by the CDC that the anti-fungal medication has side effects including toxicity to certain organisms, such as the liver,” O'Connell said. “There are hallucinations that can be associated with the drug.”

In the past, cases of fungal meningitis have been concentrated in people with disorders of the immune system.

In addition to presence of pre-existing symptoms that may mask symptoms of meningitis, diagnosis is made more difficult because even after a patient has gone through a spinal tap, it can take a long time to confirm the presence of the fungus in the spinal fluid.

Montero says attempts to precisely define a diagnosis for fungal meningitis have been like trying to hit a “moving target.”

“I expect that as more information becomes available, the definition may be changing,” he said.

Besides the four cases in New Hampshire, others may still develop. The standard now is that the disease can take four weeks to incubate, Montero said.

“There may be a long period of time that we need to be aware and alert about symptoms,” Montero said. “It may be four weeks or eight weeks or may be longer, we are still trying to come to a better understanding of how long the incubation period may be.

Montero said PainCare has been working with state officials to make sure all patients who received the injections are monitored by doctors.

“We are working with them, trying to identify the patients and trying to contact the patients, and they (PainCare) have been quite open in working with us,” Montero said.

O'Connell, the PainCare CEO, said it is important for people who received the tainted drug to be followed, especially those who had no obvious symptoms. With the discovery of cases in New Hampshire, he hopes that patients reluctant to be checked for meningitis will have a change of heart.

“They may be looking at themselves a little bit differently now, and they may wish to be seen,” O'Connell said. “What remains for us as a medical team is to handle all the patients that are out there who have been complaining of minimal symptoms, to have face-to-face contact and proceed with any diagnostic testing necessary.”


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