Connecting the Dots
Vanderbilt plays key role in identifying national meningitis outbreak
In early September 2012, a man in his 50s was brought to Vanderbilt with classic symptoms of meningitis: headache and neck pain, along with nausea, malaise, fatigue, chills and decreased appetite. His symptoms improved with antimicrobial and anti-inflammatory drugs, and he was discharged.
He returned a week later with worsening headache and appeared agitated with incomprehensible speech. He improved briefly with more medication, then worsened rapidly, became unresponsive on his 11th day of hospitalization and died on day 22.
The infectious diseases team was puzzled why a seemingly healthy man could have such a raging meningitis infection with no known cause. The team ordered the lab to retest his spinal fluid for unusual microbes.
April Pettit, M.D., MPH, was dumbfounded at what showed up on the laboratory plate – Aspergillus fumigatus, a fungus common in the environment but unheard of in a person’s spinal fluid.
“It’s rare in anyone, even in people who have immune system problems. I’ve never seen it in someone who has a normal immune system,” said Pettit, an infectious diseases specialist.
But Aspergillus filled the entire plate, and looking at the dandelion-shaped mold, Pettit began to connect the dots on what would become a nationwide outbreak of fungal meningitis.
When Pettit learned the results, she went back to the patient’s chart and interviewed his family to determine the cause. Only one thing stuck out – a spinal steroid injection at a local outpatient neurosurgery center.
Pettit said she felt in her gut that something wasn’t right and notified the Tennessee Department of Health.
“I thought this was one patient and in no way was thinking I’d found an outbreak. I just thought the only possible way that the fungus could have gotten there is through this injection and it called for investigation,” she said.
Tennessee Department of Health, and eventually the Centers for Disease Control and Prevention (CDC), began investigating and found what would end up being 696 cases of fungal meningitis, including 45 deaths, in 20 states. Tennessee was one of the hardest hit, with 147 cases and 14 deaths.
The CDC and Food and Drug Administration identified three contaminated lots of the drug methylprednisolone acetate that were implicated in the meningitis cases, all produced by the Massachusetts-based New England Compounding Center.
In January, the Tennessean named Pettit “Tennessean of the Year,” along with Marion Kainer, M.D., MPH, of the Tennessee Department of Health, who took Pettit’s notification seriously and immediately began investigating. The newspaper recognized the duo’s respective roles in the discovery of the meningitis outbreak and the lifesaving actions that followed.
Pettit says she has learned the importance of not just solving a medical problem but trying to figure out why it happened in the first place.
“It’s one thing to diagnose and treat something, but it’s taking it to another level to try to figure out where it came from or why the person got it,” she said.
“And you may not find out why. That’s what most of medicine is – we never really find out why – so it’s actually kind of gratifying to have an answer in this case.”