(HealthDay News) – Patients presenting with acute ischemic stroke may have fungal infections attributable to contaminated methylprednisolone associated with epidural injections, according to a case series published online July 22 in JAMA Neurology.

Kirk Kleinfeld, MD, from the Vanderbilt University Medical Center in Nashville, TN, and colleagues describe a case series of three patients who presented with acute ischemic stroke and received a diagnosis of fungal meningitis attributed to contaminated methylprednisolone epidural injections.

The researchers note that two of the patients were women, and the mean age of the three patients was 75.3 years. All patients had at least one traditional risk factor for stroke and had a history of epidural spinal injections of methylprednisolone for low back pain. The vascular patterns of presentation were different: two patients presented with lacunar small-vessel infarctions, while the third had a large-vessel infarct. Two of the three patients died and underwent autopsy, and Exserohilum rostratum was identified as the presumed cause of death. Fever and meningeal signs were absent at presentation in two of the patients.

“These cases highlight a diagnostic dilemma of neurologists. Patients with fungal meningitis who present with ischemic strokes may be afebrile, lack signs of meningeal irritation, and have traditional stroke risk factors,” the authors write. “An awareness of the presentation and vascular sequelae of fungal meningitis in immunocompetent patients should lead to earlier treatment and improved outcomes prior to a definitive diagnosis.”

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