A second person in the US has died in an outbreak of fungal meningitis linked to surgeries in Mexico that involved epidural anesthesia. While the case count is now up to 18, more than 200 others across 25 states may have also been exposed, the Centers for Disease Control and Prevention warned in an outbreak update Wednesday.

So far, the outbreak among US patients spans 224 people, with 206 potentially exposed and under investigation, nine suspected cases, and nine probable cases. Two of the patients with probable cases have died.

Last week, the CDC released a travel advisory and a health alert to clinicians about the cases. At the time, health authorities had identified only five cases, all Texas residents, one of whom had died. An update Wednesday from Texas health officials said that they have since identified two more cases, bringing the state's total to seven. All seven cases were hospitalized, but the officials are still reporting only one death in Texas.

The outbreak is linked to two specific clinics in Matamoros, Tamaulipas, Mexico, just across the border from Brownsville, Texas: River Side Surgical Center and Clinica K-3. Both of the clinics were closed on May 13, and the Mexican Ministry of Health sent the CDC a list of 221 US patients who may have been exposed based on records from the two clinics. But the CDC noted in its update that it has already identified at least three additional people affected who were not on the list.

Get yourself to the doctor

The people exposed had surgeries at one of the two clinics between January 1, 2023, and the time the clinics closed on May 13. Surgeries included cosmetic procedures, such as liposuction, and involved epidural anesthesia. Epidurals involve injecting an anesthetic directly into the spine in a space around spinal nerves called the epidural space.

The CDC is now working with state and local health departments to track down and investigate the 206 exposed people. Health officials are urging those people to go to a health center, urgent care facility, or hospital emergency department as soon as possible—even if they do not have any symptoms. Once there, an exposed person should tell medical staff about the exposure. The CDC even suggests people print out or share this webpage from the agency's website to make sure health care providers understand the situation. Clinicians are advised to perform MRIs and spinal taps to look for infection—again, even if there are no symptoms.

Fungal meningitis is a deadly infection in which a fungal pathogen invades the brain and spinal cord—which it can easily accomplish if it's injected directly into the spine via a contaminated epidural anesthetic. The initial symptoms of fungal meningitis are nondescript, including fever, headache, stiff neck, nausea/vomiting, extreme sensitivity to light, and altered mental status. The first five cases in the outbreak reported that the start of their symptoms ranged between one and eight weeks after their surgeries in Mexico. Treatment involves long courses of high-dose antifungal medications, often by IV at first and followed by oral treatment, the CDC says.

A second outbreak

The CDC is still investigating the specific fungal cause of the outbreak. Many fungi have the potential to cause fungal meningitis. At least one US patient has presented with elevated cerebrospinal fluid levels of the fungal biomarker (1,3)-beta-D-glucan, leading to the suspicion of fungal meningitis.

However, the CDC said Wednesday that the Mexican national laboratory (InDRE) has reported that four patients in Mexico have had spinal fluid test positive for genetic material matching the fungus Fusarium solani.

The finding echoes another large, tragic outbreak that began a year ago in Durango, a northern state directly west of Tamaulipas, which encompasses Matamoros. In that outbreak, Mexican health officials also found Fusarium solani contaminating anesthetic used for epidurals in four private hospitals. As of the latest outbreak update for May 9, 2023, the outbreak involved at least 80 cases, 39 of which were fatal. Most of the cases involved women undergoing gynecological-obstetric procedures. Epidurals are commonly used in labor and delivery, as well as other surgeries.