An outbreak of health-care associated meningitis occurred in Colombo, Sri Lanka in June- July 2005. A cluster of four cases of meningitis with atypical presentations was recognized among women who had received spinal anesthesia for cesarean sections in Colombo, Sri Lanka. Initial microbiological investigations could not precisely identify the agent involved. Two of these women died of the disease. Post mortem examination suggested that Aspergillus fumigatus was the agent implicated. The Ministry of Health of Sri Lanka and other national stakeholders reacted promptly to investigate the cluster. On the request of the Ministry of Health of Sri Lanka, a team from the World Health Organization joined the national investigation team on 17 August 2005 to provide additional technical support

In all a total of seven cases with three deaths were reported (case fatality ratio: 43%). Dates of onset ranged between the week of the 27 June and the week of 25 July 2005. Case patients were identified following exposures in three different health care facilities. Case-patients did not share a common health care facility, surgery session, operating theater, anesthesiologist or nurse. Two medications were common to six of the cases, but they were not contaminated. A large variety of injection devices used in the health care facilities and coming from three manufacturers were contaminated with Aspergillus fumigatus. Sub-standard storage conditions may have constituted the mode of contamination of these devices.

The clinical picture of the case-patients included fever, altered mental status, focal neurological deficits and subarchanoid hemorrhages. Cerebrospinal fluid findings included pleocytosis with both lymphocytes and neutophils, low glucose and high protein.. These features are compatible with the diagnosis of central nervous system infection with Aspergillus sp. Microbiological investigations indicated that Aspergillus fumigatus was the infectious agent for three of the seven case-patients. Evidence implicating this organism was available for case-patients who received spinal anesthesia in two of the three hospital involved. For three of the other four patients, the clinical picture and the initial exposure was similar to the three laboratory-confirmed cases. For the last patient, the exposure and the clinical picture were different. Another etiological agent cannot be excluded.

Aspergillus fumigatus usually affect immuno-compromised patients, causing generalized infections following exposures to mold from dust or from renovation work. It is not considered to be a pathogen of immuno-competent patients. In addition, it has not been described in the past as a cause of nosocomial meningitis following spinal anesthesia.   The currently available evidence suggests that the infection may have been due to use of injection devices which may have got contaminated during storage under unfavorable conditions.