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BACKGROUND: Fungal infection from a contaminated injection is rare (~4/10,000 injections) and can result in permanent joint damage if untreated. Infection associated with the 2012 nationwide fungal meningitis outbreak caused by contaminated methylprednisolone acetate (CMPA) injections continue to be reported. Michigan has reported 25/33 of U.S.-reported peripheral joint infections (PJIs). We describe the epidemiologic and clinical characteristics of affected Michigan patients.
METHODS: A probable case was defined as osteomyelitis or worsening inflammatory arthritis of a peripheral joint after CMPA injection after May 21, 2012. Confirmed cases also had a fungal pathogen detected through direct microscopy, culture, or polymerase chain reaction of synovial fluid, or histopathology of joint tissue. Cases were identified through active surveillance or patients self-reporting symptoms; clinical information was obtained through medical record review. All patients had magnetic resonance imaging (MRI).
RESULTS: Among the 22 probable and 3 confirmed cases, all presented with joint pain; however, 15 (60%) were among patients with symptoms unchanged from before their infection. Twenty-three patients had ≥1 underlying chronic condition, including renal insufficiency, diabetes, cardiovascular disease, and immunosuppression. Twenty-four had surgical treatment for infection, including incision and drainage, arthroscopic debridement, clavicle resection, and hip arthroplasty. Median joint aspirate white blood cell count at diagnosis was 717 cells/µL (range: 9–24,000). Median days from last injection to first MRI joint infection evidence was 70 (range: 22–171). Patients had received a median of 1 (range: 1–3) CMPA injection.
CONCLUSIONS: Approximately half of Michigan PJIs occurred among patients without new symptoms who later required surgical treatment. A higher index of suspicion should be maintained for patients who received PJIs in the absence of a gold standard for case identification.