Lessons learned in the multistate fungal infection outbreak in the United States.

The recent outbreak of fungal meningitis related to contaminated methylprednisolone acetate injections represents an important cause of morbidity and continues to be a significant public health problem in the United States. As of August 2013, there have been 749 cases and 63 deaths in 20 states associated with epidemic fungal meningitis, most of these because of Exserohilum rostratum. Clinical experience in managing these cases has grown dramatically in the last several months; most patients require at least 6 months of antifungal therapy for complicated disease. Most patients are treated with voriconazole, with or without liposomal amphotericin B, for central nervous system and paraspinal complications of the disease. For disease involving the sacroiliac and peripheral joints, voriconazole alone has been preferred. MRI spine imaging has identified several cases of asymptomatic disease, suggesting an aggressive diagnostic approach to exposed asymptomatic patients. Mortality remains low (<10%), but morbidity relating to persistent symptoms and treatment-associated toxicity is high. The ongoing fungal meningitis epidemic demonstrates an important achievement for the public health community. Important questions remain relating to the diagnosis, management, and long-term outcomes of these patients. Important research questions pertaining to specific risks influencing disease manifestations remain unanswered.