From Pathogen to Infectious Disease Diagnosis: Medical Tourism and an Outbreak of Fungal Meningitis
Last year, several cases were identified in American patients traveling to Mexico to receive cosmetic surgery. The source of transmission was discovered, and one of the investigators, Sarah Bergbower DCLS, MS, MLS (ASCP)CM, discusses her part with 1 of the cases.
Last year, Sarah Bergbower was a Doctorate of Clinical Laboratory Studies (DCLS) graduate student and rounding with the infectious disease service, when she was asked by her attending to participate in a case in what was becoming a major medical investigation.
Several cases of fungal meningitis were identified in American patients who had been traveling to Mexico to receive cosmetic surgery. For Bergbower’s team, they were focusing on 1 of the cases of an inpatient they were treating, but also there was a wider review of the overall cases being performed by the Centers for Disease Control and Prevention (CDC).
Bergbower said this presented as a challenging case, and things were not adding up in terms of a diagnosis.
“They had been managing this patient for about a month. The prognosis was not good, and over the course of that month, there were no organisms that were able to be confirmed,” Bergbower said. “Nothing grew from any cultures from any kind of source. And when they did a [cerebrospinal fluid] (CSF) panel early on, it gave false positives for both a virus which was HHV-6 and bacterium which was haemophilus influenza. And instead, they were leaning towards a fungus, because they also had a positive fungi tell assay.”
As part of the background, this patient had participated in medical tourism—the practice of traveling to other countries to receive medical care. She had traveled to Mexico for a cosmetic procedure. According to the CDC, medical tourism has been growing, with millions of Americans traveling abroad to receive medical care annually.1
During the various tests the patient underwent, there were many false-positives around fusarium and Bergbower points to this and the lack of treatment to help the patient recover. This patient, along with 11 others died from the outbreak, which was eventually linked to 1 anesthesiologist. The CDC determined the probability that the medicine this anesthesiologist used was contaminated in some way with this fungus, which was injected straight into the spinal cords of these patients who were receiving epidurals.2
“The challenge in this case, and this is just my opinion, it wasn't so much the struggle for an identification, so much that it was finding appropriate treatment, because fusarium doesn't manifest itself like your more common fungal species, and it's not treated the same way either,” Bergbower said. “When we have reports of fusarium meningitis in the literature, it's usually in the immunocompromised—not the immunocompetent—and at that they're still rare to find those so predicting and understanding what was going on and what it was doing in vivo, this was difficult, not to mention severe. Many of the patients in the outbreak experienced hemorrhage and strokes, and the fatality rate was higher than that of a previous, recent outbreak.”
Bergbower notes that although she and the team did not confirm a diagnosis, she continued her research to gain more information.
“I investigated causes of the false positives on the meningitis panels; I looked into literature that reported on similar occurrences. I correlated the other laboratory testing results with the negative cultures. So I tried to identify gaps to just further testing in efforts of making an organism diagnosis,” Bergbower explained. “So this included things like making sure that we had actually excluded everything, even what I call, you know, the zebras, the really odd possibilities. I looked for possible interactions in the fungi tell assay, because I, for one, wasn't convinced which results to believe. And I also called the medical director of the cell-free DNA next generation sequencing company to figure out why such a really cool method would fail to detect any organisms. So, all of this information I collected, I reported back to the team, and it was certainly an educational experience for everyone.”
Although the patient did expire in this case, Bergbower credits the infectious disease specialist and the fellow for their clinical management.
Bergbower has since graduated with her DCLS, and is an associate professor of Life Sciences at Olney Central College. With her DCLS accreditation, she feels she has earned the respect and trust of her provider colleagues and gained entry into the clinical side of patient management.
“I feel that the benefit of my DCLS, was that it gave me clinician speak. I could understand the actions and the rationale of the providers. I could also express laboratory concerns with them effectively, and being able to round with the providers face to face, I think, also helps establish relationships of mutual respect and trust,” Bergbower said. “I would recommend any hospital to place a laboratorian on rounds with providers, DCLS or not. For this very benefit, I strongly advocate for interprofessional diagnostic management teams, for a more holistic approach.”
