US doctors can consider spinal taps for more steroid patients-CDC

NEW YORK Wed Oct 24, 2012 5:42pm EDT

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NEW YORK (Reuters) - U.S. doctors monitoring patients for signs of fungal meningitis can consider performing spinal taps, possibly weekly, on some of those who received contaminated steroid injections, even if they show no symptoms, health officials said on Wednesday.

The revised guidelines from the U.S. Centers for Disease Control and Prevention reflect concern that the last groups of patients who received the steroid may be at a higher risk of deadly infection.

The recommendation took some physicians by surprise.

"Are we going to do spinal taps on thousands of people once a week?" asked Dr. Gary Simon, chief of infectious diseases at George Washington School of Medicine. "I think that deserves further discussion."

Twenty-four people have died and 312 have been infected after being treated with methylprednisolone acetate produced by the New England Compounding Center in Massachusetts, CDC said. As many as 14,000 people may have been exposed to the steroid before the product was recalled in late September.

Previously, the CDC had advised doctors to perform a spinal tap, which can be painful and poses its own risks, only on patients who had shown symptoms of meningitis, which include worsening headache, fever, sensitivity to light, stiff neck, and slurred speech.

On Wednesday, the CDC said doctors should consider performing a spinal tap on patients who received a steroid shot less than 42 days ago, since mathematical modeling shows that people exposed to the contaminated drug within that time are at greatest risk of developing meningitis. The agency said close monitoring without a spinal tap remains an equally valid option.

HOPING THE WORST IS OVER

The spinal tap on asymptomatic patients would reduce the risk of death or stroke from fungal meningitis from an estimated 0.4 percent to 0.3 percent compared with monitoring for symptoms alone, CDC said.

"The different risks with monitoring or tapping is pretty minimal," said Dr. Carol Kauffman, chief of infectious disease at VA Ann Arbor Healthcare System and one of six outside physicians advising CDC on the fungal meningitis cases. "But if you're one of those patients, even that small difference might make a difference to you."

The CDC still warns doctors not to give antifungal medications as a preventive measure, since the powerful drugs can cause severe side effects, including kidney and liver damage.

The CDC calculates that the risk of developing meningitis from the contaminated steroid is now less than 5 percent for all patients, and less than 1 percent for anyone who received an injection at least 42 days ago.

In Tennessee, the state where the outbreak was first identified and which has since seen the highest number of cases, health officials expressed hope that the worst of the outbreak may have passed.

"Within 15 days, patients in Tennessee will have passed the 42-day mark," said Dr. John Dreyzehner, commissioner of the Tennessee Department of Health. "This is the light at the end of the tunnel."

A government source familiar with the situation said that the revised CDC guidance reflected a desire to offer something to the "worried well," people who received injections from the tainted lots and are psychologically distraught by the uncertainty of whether they will become ill.

The revised guidance essentially gives their doctors the go-ahead to perform a spinal tap.

With a spinal tap that detects the fungus before the patient shows symptoms of meningitis, "you might pick up one or two days," George Washington University's Simon said. "But a day or two of lead time could make a difference."

(Additional reporting by Tim Ghianni in Nashville; Editing by Michele Gershberg and Stacey Joyce)

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