Beyond anesthesia: exploring the underlying causes of the fungal meningitis outbreak in the US

Infections in surgical procedures are often anticipated, and antibiotics prevent these infections. However, meningitis is rarely seen in surgical procedures. Fusarium solani, a fungal pathogen, is emerging as a potential cause of meningitis in humans. Recent reports from the Centers for Disease Control and Prevention (CDC) claim at least six confirmed cases of F. solani meningitis, with many more suspected. These cases have been linked to recent surgeries requiring spinal anesthesia in two hospitals in Metamoros, a city in Mexico. F. solani meningitis is associated with high mortality rates and demonstrates potential resistance to available therapies, which is a point of concern for healthcare authorities. In response, authorities are emphasizing proactive contact tracing of exposed individuals and advising them to undergo lumbar puncture for cerebrospinal fluid (CSF) analysis even if they are asymptomatic. This paper aims to provide an insight into the emerging outbreak of F. solani meningitis, highlighting its implications for the healthcare system, ongoing efforts to address the outbreak, and recommendations to curtail this outbreak to ensure optimal surgical outcomes for patients. The outbreak of F. solani meningitis in individuals who have undergone spinal anesthesia-related procedures poses substantial implications for the healthcare system. The disease's rarity, drug resistance, and high mortality rates emphasize the urgency for preventive measures and increased awareness. Healthcare professionals require in-depth understanding of the presentation, prevalence, and risk factors of the disease for effective management. Additionally, early screening through CSF analysis of exposed individuals, even before symptoms appear, is crucial for timely initiation of treatment and prevention of adverse disease outcomes. F. solani is a rarely presented infection, partly because it is an opportunistic infection. Immunocompromised patients with systemic fusariosis are usually critically ill, and the high mortality rate among this patient population limits clinical studies. Moreover, its diagnosis requires specialized tests like PCR and DNA sequencing, which are not readily available at every patient facility, and not all patients associated with spinal anesthesia in the recent outbreak would be undertaking these tests due to economic and social problems. Diagnosing Fusarium on microscopy is challenging as well because of its morphological similarities to Aspergillus. Preliminary identification of Fusarium infection does not determine the species, an important issue as different strains have various susceptibilities to antifungal agents. Hence, due to its rarity, opportunistic nature, specialized testing, and variable antifungal susceptibility, F. solani is hard to diagnose. F. solani exhibits resistance to antifungals due to its efflux pumps, reduced drug uptake, variability in cell wall structure, CYP51 mutations, and membrane permeability. Moreover, different strains of F. solani exhibit varying levels of susceptibility to antifungals, which further complicates treatment. Additionally, the recent association of F. solani with spinal anesthesia-related procedures presents additional challenges in its treatment. In the United States of America, the US CDC issued a level 2 travel health notice, along with recommendations for clinicians and public, on May 16 regarding fungal infections associated with procedures performed under spinal anesthesia in Mexico. Furthermore, on 24 May, the CDC published an interim recommendation for diagnosing and managing suspected cases of fungal meningitis linked to spinal anesthesia administered in hospitals of Matamoros, Mexico. A Health Alert Network message related to the outbreak of suspected fungal meningitis in patients who underwent procedures under spinal anesthesia in Matamoros was also issued by the CDC on 17 May. Since January 2023, state and local health departments have commenced contacting and conducting follow-up activities, including telephone calls and home visits, with individuals who underwent procedures involving spinal anesthesia at these two clinics. These individuals are being advised to seek diagnostic testing, including MRI and lumbar puncture, at their nearest health clinic, urgent care center, or emergency room. In Mexico, two private clinics associated with the outbreak were closed in May. Epidemiological investigations are ongoing in Matamoros, and the DGE is collaborating with State Health Services and the Matamoros Health Jurisdiction to establish operational definitions. Mexican health authorities are strengthening active epidemiological surveillance for meningitis in Tamaulipas state to ensure timely identification. A follow-up of exposed individuals has been initiated through telephone calls and home visits. On 19 May, the Mexico International Health Regulations National Focal Point (IHR NFP) notified the Pan American Health Organization/WHO (PAHO) of the outbreak of central nervous system infections (CNSI) associated with spinal anesthesia in Matamoros, Tamaulipas state. Due to the high fatality rate associated with F. solani, early detection is crucial. Treatment typically involves a combination therapy of multiple antifungals. Historically, there has been limited research on meningitis caused by F. solani. However, the recent outbreak has prompted a significant initiation of research efforts to explore the pathogenicity of F. solani, develop effective treatment options, and identify associated risk factors. To mitigate the increasing prevalence of F. solani meningitis, healthcare workers should prioritize infection prevention measures during spinal anesthesia procedures. This includes strict adherence to proper sterilization techniques and aseptic practices. Following the recommended infection control protocols and guidelines is imperative. Healthcare professionals must be well-informed about this infection to ensure its prompt diagnosis. Increasing awareness among healthcare professionals can be achieved through the provision of educational resources such as articles, research papers, and clinical practice guidelines. These resources will enable them to better understand the clinical presentation, associated risk factors, and the importance of early detection and effective management of F. solani infection. Furthermore, collaborative efforts between researchers, clinicians, and authorities are vital in developing effective and standardized treatment protocols to optimize patient outcomes. By working together, these stakeholders can contribute to improved patient care and better outcomes in tackling the challenges posed by F. solani meningitis. In a nutshell, the increasing prevalence of F. solani meningitis associated with spinal anesthesia-related procedures necessitates heightened vigilance and awareness among healthcare professionals to ensure early recognition and prompt management through CSF analysis. Preventive measures are crucial in curbing the transmission of infection associated with anesthesia-related procedures. Given its resistance to conventional antifungal treatments, early detection plays a paramount role in containing the infection and mitigating its severity. Additionally, adhering to infection control measures during spinal anesthesia procedures can significantly reduce the incidence and impact of this infection. Practices such as proper scrubbing, skin disinfection, and the use of well-sterilized equipment are of utmost importance in this regard. Ethical approval Our article is a correspondence, involving no patient's personal data, so no ethical approval was required and none taken. Consent Our article is a correspondence, involving no patient's personal data, so no consent was required and none taken. Sources of funding No sponsors were needed. Author contribution S.A.: designed the project, supervised it, proof read it, wrote the abstract and guided all authors to writing their part; S.A.: wrote the implications and challenges part, proof read the entire text, made adequate changes to improve quality of the text; M.H.B.K.: wrote the current effort part; M.H.K.: wrote the recommendations part; A.L.: wrote the conclusion part and revised the final article. Conflicts of interest disclosure None financial or personal relationships that might bias the work. Research registration unique identifying number (UIN) It is a correspondence study. No humans directly involved. Guarantor Shahzaib Ahmad. E-mail: [email protected] Data availability statement Data sharing is not applicable to this article. Provenance and peer review Our paper was not an invited one.