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  1. Fungal Meningitis Outbreak- over 300 infected, 25 deaths

    Posted by Dr. Jack Sacks, Esq.on October 27, 2012

    An outbreak of fungal meningitis due to contaminated epidural methylpredinsolone (steroid) injections, made by the New England Compounding Center, has been ongoing throughout the United States. Meningitis is a disease caused by inflammation of the meninges, the membranes that cover the brain and spinal cord. It can be caused by bacteria, viruses, fungus, physical injury, cancer, and certain medications. Fungal meningitis is generally rare and non-contagious. In the recent outbreak of fungal meningitis, the contaminant was an environmental mold known as Exerohilum rostratum, a plant pathogen that rarely causes human disease. It was identified by polymerase chain reaction assay from CSF in at least 25 patients and it has been detected in at least one unopened vial from the implicated batch of methylprednisolone . A quarter of the steroid vials in a bin at the England Compounding center contained “greenish black foreign matter” and several rooms utilized to produce sterile products demonstrated mold or bacterial overgrowth according to the FDA.

    All locations that received contaminated injections were notified and individuals who received injections from these locations were informed of the possibility of fungal infection. It is likely that not every individual who underwent an injection will contract fungal meningitis. However, individuals with underlying health conditions, circumstances surrounding the injection, and the level of contamination of a particular vial may increase susceptibility. The New England compounding center, where the injections were produced, was closed and all their products were recalled. The CDC currently reports over 300 infected and 25 deaths in patients who received contaminated injections.

    Patients should inform physicians of any symptoms such as new-onset headache, neck stiffness, photophobia, fever, or a stroke-like presentation. The incubation period is 1-4 weeks after receiving the contaminated injection. Any individual can contract fungal meningitis; however, it is often seen in individuals with weakened immune systems, such as AIDs or cancer, or individuals taking immune-suppressants, like steroids or anti-TNF medications.

    Blood cultures, imaging (Xray or CT), and lumbar puncture are used to diagnose meningitis. A definitive diagnosis is generally made by evaluating cerebrospinal fluid collected from a lumber puncture, also known as a spinal tap. CSF findings in fungal meningitis are increased pressure, increased protein, decreased glucose, and increased lymphocytes. It is essential to diagnose the specific cause of meningitis to determine treatment and severity of illness.  Fungal meningitis is generally treated with long courses of high dose intravenous antifungal medications, such as amphotericin B or flucytosine. The length of treatment depends on the patient’s immune status and type of fungus. Individuals with weakened immune systems need to remain on treatment for longer.

  2. Epidural Anesthesia and Medical Malpractice

    Posted by Dr. Jack Sacks, Esq.on October 23, 2011

    Epidural block has become a popular method of pain management during labor. However, questions persist regarding its safety and effects on mother and baby. Epidural anesthesia is a regional anesthesia, which means it blocks pain from a specific region in the body. The goal of a labor epidural is to block pain impulses from lower spinal segments that can result in decreased feeling in the abdominal and pelvic area. Optimally, this decreases the pain experienced during contractions and labor; however, it allows the patient to retain enough feeling to push the baby out when full cervical dilation is reached.



    A combination of medicines is commonly used in epidural anesthesia. These include local anesthetics such as bupivicane, marcaine, or lidocaine, to numb the area; opioids such as fentanyl, or morphine, to decrease pain sensation; and other medication such as epinephrine type drugs that can be used to stabilize the mother’s blood pressure.

    Although an epidural may be beneficial due to decreases in labor pain, there are associated risks as well. Maternal side effects can include pain at the spinal injection site as well as leakage of spinal fluid than can cause severe headaches (“spinal headache”) that may require additional treatment.Epidural anesthesia may slow the labor and increase the use of operative delivery techniques such as cesarean section, forceps, or vacuum extraction.

    If medical malpractice occurs during placement and management of epidural anesthesia, injury to the newborn may result. After epidural placement, the patient may sustain a drop in blood pressure. The drop in maternal blood pressure may decrease the amount of blood travelling across the placenta and lead to a decrease in blood, oxygen, and nutrients reaching the baby. If the baby was adversely affected by an epidural, there may be abnormal changes in the fetal heart rate pattern.

    Medical malpractice may occur in the context of failing to properly manage maternal hypotension (low blood pressure). Decelerations or other non-reassuring patterns in the fetal heart rate can indicate impending damage to the newborn. It is essential that these complications are managed in a timely fashion with appropriate medical intervention to avoid brain injury to the baby from oxygen deprivation.

    For example, if the mother’s blood pressure decreases significantly from the epidural, medications can be given to mitigate this effect and raise the blood pressure. By raising the maternal blood pressure, proper placental blood flow is restored or maintained and the baby will be less likely to suffer injury. In addition, oxygen may be administered to the mother during the labor epidural. This can increase the amount of oxygen in the maternal blood, and thereby increase the amount of oxygen in the blood that reaches the baby. This will also serve to decrease the likelihood of fetal injury.

    Medical malpractice may occur when maternal blood pressure drops too low causing less oxygen and nutrients to reach the fetus. The baby can suffer permanent brain injury from lack of oxygen. This can manifest as seizures, cerebral palsy, or developmental delay.