Fungal Meningitis Outbreak Associated with Procedures Performed under Epidural Anesthesia in Matamoros, Mexico

Background

CDC, the Mexican Ministry of Health, and U.S. state and local health departments are responding to a multinational outbreak of fungal meningitis among people who had procedures under epidural anesthesia in Matamoros, Tamaulipas, Mexico. Officials identified two clinics associated with the outbreak: River Side Surgical Center and Clinica K-3. These clinics were closed on May 13, 2023. Anyone who had procedures under epidural anesthesia in these clinics from January 1 to May 13, 2023, is at risk for fungal meningitis. Learn what to do if you are at risk.

The Mexican Ministry of Health provided CDC a list of U.S. residents who had procedures at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023. Using this list, CDC and state and local health departments are trying to reach all people at risk but continue to face challenges. Some of the listed contact information is incorrect or incomplete and some at-risk persons have been identified who were not on the list.  These people are being reached through outreach efforts like media and social media and through family, friends, and other contacts found during public health investigations. Health departments are encouraged to continue to raise awareness. CDC’s social media toolkit for partners provides graphics, videos, and messaging in English and Spanish to help with these efforts.

Anyone who is at risk for fungal meningitis should go to the nearest emergency room right away to be tested. Testing is done by a lumbar puncture (LP), also called a spinal tap. People who are infected should begin antifungal treatment as soon as possible.

Information for People at Risk

If you had epidural anesthesia in Matamoros, Mexico, at River Side Surgical Center or Clinica K-3 from January 1 to May 13, 2023:

• Go to the nearest emergency room as soon as possible to be evaluated for fungal meningitis, even if you do not currently have symptoms.
  • Some people without symptoms or with mild symptoms have tested positive for infection and started treatment. Receiving treatment early can prevent severe illness.
  • Fungal meningitis can start off mild and very quickly become a life-threatening illness.
  • Consider printing and sharing this web page to help make sure staff and healthcare providers are aware of the situation and recommended tests.
• If you cannot go to an emergency room (for example, because it is too far away), consider calling your local health center or urgent care facility to see if they can do spinal taps. In most situations, the emergency room will be the best or only option for testing.

When you arrive, tell emergency room staff that you need to be evaluated for possible fungal meningitis. Tell them that you recently had epidural anesthesia at one of the clinics in Mexico involved in this outbreak.

If you had epidural anesthesia in Mexico at other clinics:

• To date, all of the people who got fungal meningitis after a procedure under epidural anesthesia had their procedures at one of two clinics: River Side Surgical Center and Clinica K-3
• All procedures involving epidural anesthesia carry some risk of infection. If you had a procedure in Mexico at any other clinic, develop symptoms of meningitis, and are concerned that you could have meningitis, contact your healthcare provider.

What to Expect

• Healthcare providers will perform a spinal tap by inserting a needle into your lower back in a space around your spine to collect fluid for laboratory testing. This is recommended even if you do not currently have symptoms.
• The fluid will be tested in a laboratory to determine if you have fungal meningitis.
• If you test positive for infection: your healthcare team will treat you with antifungal medicines in the hospital. When you go home, you will need to take antifungal medicine for at least 3-6 months to completely cure the infection.
• If you test negative for infection: It is possible to test negative during the early phases of infection. This is called a false negative. If you develop new or worsening symptoms, you should return to the emergency room as soon as possible.
  • Your healthcare provider may ask you to come back in 2 weeks to repeat the spinal tap.
  • Watch for symptoms for at least 30 days after the first spinal tap.

Information for Healthcare Providers

Healthcare providers should immediately report suspected fungal meningitis cases, including those possibly related to this outbreak, to their state or local health department. Find contact information for your jurisdictional HAI program coordinator.

Interim Recommendations for diagnosis and management of cases (with or without symptoms) of possible fungal meningitis associated with epidural anesthesia administered in Matamoros, Mexico:

• Interim Recommendations for Diagnosis and Management of Fungal Meningitis Associated with Epidural Anesthesia Administered in Matamoros, Mexico [PDF – 7 Pages] (7/18/2023)
• One page summary of interim recommendations [PDF – 1 Page]
• Clinical diagnosis and treatment algorithm [PDF – 1 Page]

These interim recommendations:

• Provide detailed diagnostic and management recommendations for clinicians caring for patients who underwent a procedure under epidural anesthesia in the city of Matamoros.
• Are based on the clinical experience and expert opinion of clinicians caring for patients during the current outbreak or during previous outbreaks of healthcare-associated fungal meningitis in Durango, Mexico, and the United States. It will be updated as additional information becomes available.
• This assessment involves a lumbar puncture to collect cerebrospinal fluid (CSF) for diagnostic laboratory testing.

Testing Asymptomatic Patients

• Perform the diagnostic assessments in the interim recommendations on all patients with potential exposure, regardless of symptoms, to provide the best chance of preventing widespread morbidity and mortality from this outbreak for the following reasons:

1. The latency of symptom onset in some affected patients provides a window of opportunity to identify infection and begin treatment early enough to prevent severe or life-threatening illness:
   • Patients without symptoms or with mild symptoms have tested positive for infection.
   • Symptom onset ranges from 3 days to 4 weeks after the date of exposure among reported cases to date.
   • Fungal meningitis may progress rapidly once symptoms start, causing more severe and harder to treat illness.
2. The potential of high case-fatality rates related to this illness:
   • The fungus implicated in this outbreak (Fusarium solani) was associated with a 50% case-fatality rate during a recent outbreak of healthcare-associated central nervous system infections in Durango, Mexico.
   • Antifungal susceptibility testing of a strain of Fusarium solani isolated from a U.S patient showed that the isolate is highly resistant.

Testing Patients Not Associated with this Outbreak

• To date, all people with confirmed fungal meningitis infections in the current outbreak have been linked to two clinics in Matamoros, Mexico (River Side Surgical Center and Clinica K-3).
• People who had procedures under epidural anesthesia at other clinics in Mexico and develop symptoms are encouraged to contact their healthcare provider if they are concerned about possible meningitis.
• Healthcare providers who suspect possible meningitis should perform a lumbar puncture (unless contraindicated). If the initial lumbar puncture results are abnormal, healthcare providers can request additional testing for fungal pathogens (e.g., Beta-D-Glucan, fungal PCR).

Information for Health Departments

Health Departments

• • CDC has notified states and local jurisdictions where any patients live who were listed by the Mexican Ministry of Health as potentially at risk.
    • Health departments are notifying patients and telling them to go to an emergency room for testing. CDC developed resources to assist with notifying hospitals and patient notification.
    • Health departments can email CDC at FungalOutbreak@cdc.gov for resources and additional support.
  • All health departments can help raise awareness about the outbreak to help reach more people who may be at risk and encourage them to take the recommended actions.
    • Some people at risk were not included in the original list used to notify patients. They have been found and contacted through public health investigation, outreach efforts, social media, and by family and friends as they learn about the outbreak.
    • For more information about medical tourism and risk mitigation, see CDC Yellow Book 2024: Medical Tourism or contact medicaltourism@cdc.gov.

U.S. Cases under Investigation, Case Counts, and Deaths as of 8/31/23

¹ Meningitis symptoms include fever, headache, stiff neck, nausea, vomiting, photophobia, and altered mental status.

² Cerebrospinal fluid (CSF) profile with >5 WBCs/mm³, accounting for the presence of red cells (i.e., subtracting 1 white cell for every 500 RBCs present).

³ Fungus could be detected by culture, polymerase chain reaction (PCR) testing, or metagenomic next generation sequencing (mNGS) testing of CSF or tissue. Only select laboratories in the U.S. can test for the type of fungi involved in this outbreak creating a lag time between the spinal tap and receiving results.

⁴ Three probable cases and nine confirmed cases.

Findings and Investigations

Select key findings:

• Elevated levels of Beta-d-glucan, a biomarker of fungal infection, have been detected in the CSF of some U.S. patients.
• Three U.S. laboratories (CDC Mycotic Diseases Branch’s Laboratory, UCSF Clinical Microbiology Laboratory, and UW Medicine Molecular Microbiology Laboratory) and the Mexican national laboratory (InDRE) have detected fungal signals consistent with the Fusarium solani species complex from the CSF of patients receiving care in Mexico or the United States.
• Antifungal susceptibility testing of a strain of Fusarium solani isolated from a U.S patient showed that the isolate is highly resistant.

Continuing investigations:

• CDC and partners are investigating to determine how people were exposed to the infectious organism(s) during the procedures.
• Officials are investigating whether any additional clinics were involved.

What CDC Is Doing

• Distributed a Health Alert Notice (HAN) Health Advisory and HAN Health Advisory Update
• Collaborated with the Mycoses Study Group to develop clinical resources: Interim Recommendations, a One-page Summary of Interim Recommendations, and an Algorithm for diagnosis and treatment.
• Collaborated with the Mycoses Study Group to produce a webinar discussing epidemiology, diagnostics, and treatment
• Held a Clinician Outreach and Communication Activity (COCA) webinar describing Interim Recommendations describing epidemiology, diagnostics, and treatment.
• Facilitating outreach to potentially impacted patients
• Coordinating and performing specimen testing
• Continuing to investigate the source of the outbreak with colleagues in Mexico
• Disseminating information and strategic outreach to clinicians, the public, and partners
• Providing technical, diagnostic, and clinical advice as requested

Summary of Previous Updates