Correspondence

Aspergillus Meningitis in Sri Lanka — A Post-Tsunami Effect?

N Engl J Med 2007; 356:754-756February 15, 2007

Article

To the Editor:

An outbreak of meningitis from infection with Aspergillus fumigatus after the administration of spinal anesthesia for cesarean section occurred between July 2 and July 25, 2005, in Colombo, Sri Lanka. The patients were five previously healthy women. Their median age was 27 years (range, 21 to 38) (Table 1Table 1Characteristics of Patients with Iatrogenic Meningitis in the 2005 Outbreak.). They had received spinal anesthesia from different surgical teams in two maternity hospitals. The mean incubation period was 11.2 days. Fever, headache, and nuchal rigidity were common presentations. Remittent fever continued despite initial treatment with broad-spectrum intravenous antibiotics. Papilledema, lateral rectus palsy, and cerebral infarction and hemorrhage developed later in the course of the disease, despite the addition of empirical fluconazole therapy. Three patients died. Cerebrospinal fluid was characterized by pleocytosis (>1000 neutrophils and lymphocytes per cubic millimeter) with a low glucose level and a negative polymerase-chain-reaction assay for fungi.1 Fungal cultures of cerebrospinal fluid or postmortem brain specimens from four patients were positive for A. fumigatus. Postmortem examination of Patient 1 confirmed aspergillus meningitis (Table 1), which led to immediate treatment with amphotericin B, voriconazole, or both in Patients 3 and 4.2 One year later, Patient 3 had residual visual and hearing impairments, and Patient 4 had no residual abnormalities. The children were unaffected.

Intensive microbiologic investigations commenced when the possibility of an outbreak was recognized. These included examination of randomly selected, unopened packages of medical supplies: 679 disposable plastic syringes, 159 intravenous and spinal needles, 87 cannulae, and 55 ampules of anesthetic agents. Fungal cultures confirmed that 43 syringes from three different manufacturers were contaminated with A. fumigatus.3 The Ministry of Health's central stores of drugs and devices were then examined, since infection occurred in two different hospitals. This revealed that the three regularly used, renovated warehouses were full of donations for survivors of the tsunami, whereas the regular procurements of the ministry were stored in a dusty and humid fourth warehouse with leaks in the roof. Although the exact source of the contamination remains unclear, inadequate storage facilities, owing to the mass influx of donations, was identified as the most plausible explanation, given the suboptimal storage conditions during the 6-month period after the tsunami disaster. Immediate incineration of all unused syringes led to effective control of the outbreak, with no reports of aspergillus meningitis in 2006.

Aspergillus meningitis has a high fatality rate.4 The survival of the two women aggressively treated for aspergillus meningitis shows the importance of both specific diagnostic tests leading to early recognition of the outbreak and the administration of appropriate treatment. However, caution should be used in administering empirical antifungal treatment in immunocompetent, low-risk patients because of possible side effects.5

Padma S. Gunaratne, M.D.
National Hospital of Sri Lanka, Colombo 005, Sri Lanka
pagunara@hotmail.com

Chandrika N. Wijeyaratne, D.M.
Harshalal R. Seneviratne, D.M.
University of Colombo, Colombo 005, Sri Lanka

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Citing Articles (9)

Citing Articles

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   S. Schwartz, A. Reisman, P. F. Troke. (2011) The efficacy of voriconazole in the treatment of 192 fungal central nervous system infections: a retrospective analysis. Infection 39:3, 201-210
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   Arunaloke Chakrabarti, Shiv Sekhar Chatterjee, Ashim Das, M. R. Shivaprakash. (2011) Invasive aspergillosis in developing countries. Medical Mycology 49:S1, S35-S47
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3. 3

   Farrah J. Mateen. (2010) Neurological disorders in complex humanitarian emergencies and natural disasters. Annals of Neurology 68:3, 282-294
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4. 4

   Jonathan R. Genzen, Barton Kenney. (2009) Central nervous system Aspergillus infection after epidural analgesia: diagnosis, therapeutic challenges, and literature review. Diagnostic Microbiology and Infectious Disease 65:3, 312-318
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5. 5

   S. Schwartz, E. Thiel. (2009) Cerebral aspergillosis: tissue penetration is the key. Medical Mycology 47:s1, S387-S393
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   David J. Weber, Amanda Peppercorn, Melissa B. Miller, Emily Sickbert-Benett, William A. Rutala. (2009) Preventing healthcare-associated Aspergillus infections: review of recent CDC/HICPAC recommendations. Medical Mycology 47:s1, S199-S209
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   A. Biglino, P. Crivelli, E. Concialdi, C. Bolla, G. Montrucchio. (2008) Clinical Usefulness of ELISPOT Assay on Pericardial Fluid in a Case of Suspected Tuberculous Pericarditis. Infection 36:6, 601-604
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   Felicity Reynolds. (2008) Neurological Infections After Neuraxial Anesthesia. Anesthesiology Clinics 26:1, 23-52
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   N. Rodrigo, K.N.T. Perera, R. Ranwala, S. Jayasinghe, A. Warnakulasuriya, S. Hapuarachchi. (2007) Aspergillus meningitis following spinal anaesthesia for caesarean section in Colombo, Sri Lanka. International Journal of Obstetric Anesthesia 16:3, 256-260
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