Contaminated Injection for Back pain in North Carolina North Carolina Division of Public Health (NCDPH) was notified of two cases of meningitis caused by a rare fungus in patients who had received epidural injections at outpatient pain management clinics. Two cases of fungal infection associated with contaminated drugs prepared at a compounding pharmacy. Clinicians should consider the possibility of improperly compounded medications as a source of infection in patients after epidural or intra-articular injections. A woman aged 77 years with chronic low back pain was admitted to hospital A in North Carolina with a 4-day history of progressive diffuse headache, fever, chills, and malaise with subsequent development of vertigo, nausea, and vomiting. She was febrile (100.4º F [38.0ºC]) and had slight nuchal rigidity. Analysis of cerebrospinal fluid (CSF) was consistent with meningitis: 979 white blood cells (WBC)/mm3 (normal: <10 WBC/mm3) with 63% neutrophils, protein of 134 mg/dL (normal: 15--45 mg/dL), and glucose of 38 mg/dL (normal: 40--80 mg/dL). The patient showed no improvement on antibacterial drugs, and a follow-up CSF analysis on July 18 revealed yeast-like elements on microscopic examination. The patient was treated with amphotericin B and transferred to hospital B in North Carolina. On July 24, a fungus cultured from CSF was identified as Exophiala (Wangiella) dermatitidis. Amphotericin B was discontinued, and voriconazole and flucytosine were started. The patient's condition continued to deteriorate, and she died 51 days after hospitalization. The patient had been treated at pain management clinic A in North Carolina and had received lumbar epidural injections with methylprednisolone acetate 100 and 35 days before hospital admission. The injectable methylprednisolone had been prepared by compounding pharmacy A in South Carolina. A woman aged 61 years who was being treated for chronic low back pain at pain management clinic A was admitted to hospital A after CSF obtained during a myelogram was consistent with meningitis (820 WBC/mm3 with 52% neutrophils, protein of 108 mg/dL, and glucose of 57 mg/dL). The patient had a 3--5 day history of mild headache, subjective fever, chills, sweats, and mild neck stiffness. The patient had received lumbar epidural injections at pain management clinic A 84 and 34 days before hospital admission. The injections contained methylprednisolone acetate prepared by compounding pharmacy A. CSF grew yeast, later identified as E. dermatitidis, 27 days after collection. The patient was begun on intravenous voriconazole and later switched to oral voriconazole; as of December 5 (70 days into therapy), her condition had improved.