A 19-state outbreak tied to contaminated steroid injections is growing in cases of those who have been infected, however the new increase appears to more pronounced in non-meningitis infections.
There have been 478 cases of fungal meningitis or related infections as of Nov. 19, according to the Centers for Disease Control and Prevention, plus 12 peripheral joint infections in areas such as the knees, hips, shoulders and elbows where people may have gotten the shots. Thirty-four people have died.
The outbreak is tied to methylprednisolone acetate steroid injections used to treat pain that were made by the specialty pharmacy, the New England Compounding Center of Framingham, Mass.
The CDC announced Tuesday that it is still receiving reports of infections more than seven weeks after the September recall of more than 17,000 vials of injections of the steroid made by the NECC; however, the pattern now reflects an uptick infections at the site where patients received the injection. Those infections include epidural abscesses, phlegmon (soft tissue infection), discitis (infection of disc space between vertebrae), vertebral osteomyelitis (a bone infection) or arachnoiditis (swelling of one of the spinal cord membranes).
The infections are being found in both people who have already been diagnosed with fungal meningitis and people who haven't been. The CDC said Wednesday that there may not be new infections in those people, but because the fungus tied to the outbreak -- Exserohilum rostratum -- is slow-growing, the infections may have been building up.
"This isn't something new happening, but something that's coming to light after a much longer incubation period," Dr. J. Todd Weber, incident manager for response to the fungal meningitis outbreak and chief of prevention and response at the CDC's division of healthcare quality promotion, told CBSNews.com Wednesday.
Of the 91 cases reported to CDC since November 4, 2012, a total of 26 (29 percent) were classified as meningitis, 61 (67 percent) had spinal or paraspinal epidural abscess or osteomyelitis, two (2 percent) had peripheral joint infection, and two (2 percent) had more than one condition.
The most common of these non-meningitis infections, an epidural abscess, is a collection of puss near the site of the injection. The main symptom of this infection is back pain, but Weber noted many of the patients who received these injections were treated for back pain, and may not realize another infection is present.
While some people may experience swelling or redness, many won't, so the only way to determine the presence of an infection is through magnetic resonance imaging scans (MRI).
The CDC assisted state health departments in contacting most of the 14,000 people who may have received the injections early in the outbreak. Not all of those patients will be contacted again, but Weber reemphasized the CDC's original guidance that patients who may be experiencing symptoms should contact their doctor.
"The message I would give, for any patient who was exposed, if new symptoms develop they should be evaluated and the fungal infection should be considered," said Weber.
In Tennessee, which has seen 82 total cases tied to the contaminated injections as of Nov. 19, health officials announced they would begin contacting 1,009 patients who received the injections that had previously been contacted for meningitis risk, but now will be told to be on the lookout for signs of an infection, reports The Tennessean.
"Tennessee is going to be very proactive," Dr. William Schaffner, an infectious disease researcher at Vanderbilt University who is assisting the state, told the paper.
Last week House lawmakers questioned Dr. Margaret Hamburg, chief of the Food and Drug Administration along with one of the owners of the New England Compounding Center, Barry Cadden about the current outbreak. They asked about the company's history of repeat violations and earlier FDA inspections of the firm that found non-sterile practices.
Hamburg called for more oversight of compounding pharmacies, which are regulated by state health departments, while Cadden plead the Fifth Amendment and did not answer the committee's questions.