19 more meningitis cases linked to steroid injections

• Nationally, there are 233 total cases in 15 states
• 15 people have died so far
• Cases are linked to injections sold by the New England Compounding Center

Nineteen more cases of fungal meningitis infections related to contaminated steroid injections were reported Tuesday, bringing the national total to 233 in 15 states, the Centers for Disease Control and Prevention said. Fifteen have died.

The newly-reported cases are in nine states: Florida, 2; Indiana, 2; Maryland, 1; Michigan, 1; New Hampshire, 2; New Jersey, 2; Ohio, 2; Tennessee, 6; Virginia, 1.

The cases are all linked to joint-pain steroid injections sold by the now-closed New England Compounding Center (NECC) in Framingham, Mass.

On Monday, the Food and Drug Administration announced that the New England Compounding Center is also the focus of federal warnings about other drugs it makes that may be linked to new infections.

Health officials have identified one case of meningitis potentially associated with an injection of a different NECC steroid for joint pain. Another case involved a patient who got a fungal infection after receiving another NECC drug during surgery. Investigators don't yet know if the infection is linked to the NECC drug.

As of Tuesday, the FDA said it did not know how many patients might have been exposed to the possibly contaminated drugs. NECC made about 1,200 products, all of which are listed on FDA's website.

More than 90% of patients who had potentially been exposed to the contaminated steroid injections had been notified, said Melissa Dankel, of the Centers for Disease Control and Prevention's Division of Healthcare Quality Promotion. Now they must wait to see whether they develop meningitis symptoms.

The diagnosis for meningitis requires a spinal tap, which involves inserting a needle into the spinal cord to remove fluid that is then tested.

The fungal infections develop slowly. In this outbreak, symptoms have typically appeared between one and four weeks following the contaminated injection, the CDC said. Health officials, however, warn that longer periods of time between injection and onset of symptoms have also been reported.

The anti-fungal medication given to treat the infection is itself potentially toxic and must be given carefully. Though it is an oral drug, the initial treatment must be done in the hospital so patients can be monitored for possibly dangerous side effects. After the initial treatment patients can take subsequent doses as outpatients, Dankel said. Side effects can include "visual disturbances and kidney failure," she said.

The anti-fungal treatment can be given even after meningitis symptoms, for example head ache or stiff neck, develop.

On Tuesday, Rep. Edward Markey, D-Mass., asked the Department of Justice to investigate whether the New England Compounding Center also violated laws related to the sale of controlled substances. On the list of recalled NECC products are nearly 1,000 formulations that contain controlled substances including cocaine, morphine and ketamine. Such formulations can only be sold by pharmacies registered with the federal Drug Enforcement Administration.

Pharmacies can only sell controlled substances directly to patients who have a prescriptions, if the pharmacy is not registered with the DEA as a manufacturer or supplier. The NECC is not.

"This is a matter that I believe requires further investigation by the DEA to ensure that this facility, already believed to have broken Massachusetts state law, has not also skirted federal law related to controlled substances," Markey said in the letter to the Justice Department.

Contributing: Liz Szabo and Dan Vergano