Combo Therapy Helps Knock Out Fungal Meningitis

Study found 2-drug treatment reduced death risk from cryptococcal meningitis by 40 percent

By Serena Gordon

HealthDay Reporter

WEDNESDAY, April 3 (HealthDay News) -- A drug regimen containing two powerful antifungal medicines -- amphotericin B and flucytosine -- reduced the risk of dying from cryptococcal meningitis by 40 percent compared to treatment with amphotericin B alone, according to new research.

The study also found that those who survived the illness were less likely to be disabled if they received treatment that included flucytosine.

"Combination antifungal therapy with amphotericin and flucytosine for HIV-associated cryptococcal meningitis significantly reduces the risk of dying from this disease," said the study's lead author, Dr. Jeremy Day, head of the CNS-HIV Infections Group for the Wellcome Trust Major Overseas Program in Vietnam.

"This combination could save 250,000 deaths across Africa and Asia each year. The key to achieving this will be improving access to the antifungal agent flucytosine," said Day, also a research lecturer at the University of Oxford.

Flucytosine is more than 50 years old and off patent, according to Day. The drug has few manufacturers, and it isn't licensed for use in many of the countries where the burden from this disease is highest, he said. Where it is available, the limited supply often drives the cost higher, Day noted.

"We hope the results of this study will help drive increased and affordable access to both amphotericin and flucytosine," he said.

Infectious disease specialist Dr. Bruce Hirsch, an attending physician at North Shore University Hospital in Manhasset, N.Y., said that in the United States, "the use of these medicines, amphotericin and flucytosine, is the usual standard of care for this dangerous infection, and is followed by long-term treatment with fluconazole [another antifungal]."

But, Hirsch noted that this infection is unusual to see in the United States.

That's definitely not the case in the rest of the world. There are about 1 million cases of cryptococcal meningitis worldwide each year, and 625,000 deaths associated with those infections, according to study background information.

Meningitis is an infection of the meninges, the protective membranes that cover the brain and the spinal cord. Meningitis can be caused by bacteria, viruses and fungi, according to the U.S. Centers for Disease Control and Prevention. Cryptococcal meningitis is caused by the fungus Cryptococcus. There are 30 strains of Cryptococcus, and one that often causes disease is Cryptococcus neoformans.

"Most of us have been exposed to Cryptococcus neoformans. It is ubiquitous in the environment, associated with trees, bird guano and soil. Infection is thought to occur from the inhalation of spores," Day said.

People can be infected for years without knowing it, according to Day. But, if someone who's infected has weakened immunity, the infection can then start to wreak havoc. Common ways people become immune-suppressed are through an HIV infection, taking immune-suppressing medications for organ transplantation, or taking immune-system altering medications for chronic inflammatory diseases, Day explained.

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Valley Fever Fungal Infection on Rise in Southwest

Title: Valley Fever Fungal Infection on Rise in Southwest
Category: Health News
Created: 3/28/2013 4:36:00 PM
Last Editorial Review: 3/29/2013 12:00:00 AM

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Valley Fever Fungal Infection on Rise in Southwest

Flu-like symptoms can last weeks or months, CDC researchers say

By Robert Preidt

HealthDay Reporter

THURSDAY, March 28 (HealthDay News) -- Cases of a fungal lung infection called Valley Fever increased sharply in several southwestern states since the late 1990s, according to a report released Thursday.

In Arizona, California, Nevada, New Mexico and Utah, the number of cases climbed from less than 2,300 in 1998 to more than 22,000 in 2011, the U.S. Centers for Disease Control and Prevention found.

During that time, Arizona and California had the largest average increases in Valley Fever incidence, at 66 percent and 31 percent per year, respectively.

Valley Fever (Coccidioidomycosis) is caused by inhaling a fungus called Coccidioides, which lives in the soil in southwestern states. Not everyone who is exposed to the fungus gets sick, but those who do become ill typically have flu-like symptoms that can last for weeks or months.

More than 40 percent of patients who get sick may require hospitalization, with an average cost of nearly $50,000 per visit. And research has shown that 75 percent of those who get sick miss work or school for about two weeks, the CDC said.

Between 1998 and 2011, nearly 112,000 cases of Valley Fever were reported in 28 states and Washington, D.C., but 66 percent of the cases were in Arizona, 31 percent were in California, 1 percent were in Nevada, New Mexico and Utah, and about 1 percent were in all other states combined.

More research is needed to determine what is causing the increase in Valley Fever and how to reduce its effects, the CDC said. Possible reasons could be population growth, weather changes that could affect where the fungus grows and how much of it is circulating, or changes in the way the disease is detected and reported to the CDC.

"Valley Fever is causing real health problems for many people living in the southwestern United States," Dr. Tom Frieden, director of the CDC, said in an agency news release. "Because fungus particles spread through the air, it's nearly impossible to completely avoid exposure to this fungus in these hardest-hit states. It's important that people be aware of Valley Fever if they live in or have traveled to the southwest United States."

Doctors and patients need to be aware that the symptoms of Valley Fever are very similar to flu or pneumonia symptoms, the CDC said. A lab test is the only way to diagnosis Valley Fever.

Not everyone who gets Valley Fever requires treatment, but early diagnosis and treatment are important for those at risk for the more severe forms of the disease. Those at higher risk for severe disease include people of Asian descent (particularly Filipino), blacks, pregnant women and people with weakened immune systems, according to the CDC website.

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Fungal Meningitis Patients: A Long Road to Recovery

Dec. 26, 2012 -- Johnnie McKee thought she was out of the woods.

McKee, a 72-year-old grandmother of four from Bethpage, Tenn., was one of nearly 14,000 people who found out this fall that they'd been exposed to tainted medications made by the now shuttered New England Compounding Center.

In her case, the threat came from a steroid shot that she'd had on Sept. 7 to relieve some nagging back pain.

"We got a letter. We were told that if we could make it 28 days, that we'd be clear," says Fred McKee, her husband of 51 years. "We watched it and worried about it," says Fred, his voice filling with emotion.

But Johnnie felt fine. She didn't have any of the symptoms they were told to look for -- headaches, nausea, fever.

The waiting period passed, and she felt good enough to get back to her yard, which she had always tended with great care. "She mowed the lawn," says Fred.

Then, on Oct. 8, the pain hit like a bolt of lightning at the base of her spine. "It was just excruciating pain," says Fred. Their surgeon told them to drive to the emergency room at St. Thomas Hospital in Nashville, where doctors had started to treat a wave of patients who were battling a rare type of fungal meningitis, an infection of the brain and spinal cord.

"There were three criteria they looked for to determine if you have fungal meningitis, and she met all three," Fred says.

Still, he says, they didn't worry. But that may have been because they didn't understand what was coming.

"I don't think we really realized that we were really getting into a two- to three-month hospitalization period and a six-month-to-a-year complete recovery," he says.

Since the outbreak began, 620 people have been infected and 39 have died in 19 states. No one has been cured.

"As far as we know, no one has been taken off medicines, and we wouldn't recommend that now; it's still too early," says Tom M. Chiller, MD, MPH, deputy chief of the Mycotic Diseases Branch at the CDC in Atlanta.

Many hope they are on the road to recovery, but no one can tell them when it will end.

Experts say they've never seen these kind of fungal infections, much less this many cases.

"It's very difficult for the doctors and the patients because we can't say, 'Well, just two more weeks of this and it will be over.' What we're saying is that we're going to keep treating you. We're going to keep caring for you, and when the experts tell us we can stop, we're going to do that," says William Schaffner, MD, an infectious disease specialist at Vanderbilt University in Nashville.

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