Treatment of iatrogenic fungal infections: a black mold defines a new gray zone in medicine.

Defining appropriate medical treatment incorporates evidence to balance risk and benefit. Yet, sometimes physicians find themselves in an uncomfortable “gray zone” that necessitates decision making with a paucity of data. This gray zone is where we find ourselves as we struggle to manage an outbreak of central nervous system (CNS) and joint infections that occurred due to injection of methylprednisolone acetate contaminated with filamentous fungi when poor sterility practices were used at a compounding pharmacy in Massachusetts. The outbreak, now recognized to be predominantly due to a black mold, involves more than 14 000 persons with potential exposure to contaminated medication. As of 10 December 2012, the Centers for Disease Control and Prevention (CDC), which provides frequent updates on the investigation and treatment recommendations, had documented 368 cases of meningitis, 192 cases of paraspinal/spinal infections, and 21 cases of arthritis clustered in 19 states, with 37 deaths (1). We focus here on questions likely to be on the minds of clinicians.