The recent meningitis outbreak in the US was quickly linked to a  fungal infection caused by steroid injections from a Massachusetts compounding pharmacy, and the focus of the investigations has focused on what breakdown in procedures led to the contamination. What has received less publicity is just how the mystery was solved in the first place.

According to recent media accounts by ABC News and others, the credit for cracking the case goes to April Pettit, an infectious disease clinician at Vanderbilt University Hospital and Marion Kainer, a former Epidemic Intelligence Service officer at CDC and now Tennessee State Health Department epidemiologist working on health-care associated infections. According to media accounts, Pettit was  astute and ordered the right laboratory tests when a patient she had treated for bacterial meningitis appeared to relapse and returned to the hospital. Also, when the lab results indicated a rare fungal infection, Pettit inteviewed the family and elicited a history of a recent spinal steroid injection. At that point, she recognized the potential public health implications of the situation and acted responsibly to quickly report the case to the Health Department.

That report came to Kainer who did active casefinding. CDC did not know of other cases but two more Nashville meningitis cases from the same clinic with a history of steroid injections turned up. At that point, interest in the mystery quickened and   deepened around questions about the source of the fungus—in the clinic environment, in the steroid material itself, or in the needles used to give the injections.  When it was learned that one of the sources of the steroid material was a compounding pharmacy in Massachusetts, Kainer’s index of suspicion went up since compounding pharmacies have been previously associated with outbreaks of various kinds.

As additional cases rolled in, more casefinding efforts were carried out statewide and specific followup efforts were begun for the more than 150 patients who have been treated at the Nashville clinic. When the compounding pharmacy suddenly recalled three lots of the steroid, CDC put out a national health alert. This turned up a probable case in North Carolina and this person also had an injection from the drug in one of the recalled lots. Also, the Tennessee follow up data showed a dose-response effect because patients who received a larger dose were more likely to get ill.

Investigations have turned up other cases and a death that occurred prior to the case in Tennessee but these went unreported. The team in Tennessee is credited with the right thinking and the right actions needed to solve the mystery. Their quick work is credited with saving lives because further delay would have meant delays in treatment for many exposed persons.

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