The Tennessee Department of Health confirmed Friday that four more cases of fungal meningitis have been identified in Tennessee, bringing the total to 29.
The health department said three people have died from the outbreak in Tennessee. There have been five confirmed deaths nationwide.
Health officials urge healthcare providers not to use any materials from the New England Compounding Center, the Massachusetts pharmacy identified as having provided the steroid product to several facilities in 23 states.
Officials ask at-risk patients to continue to follow-up with medical personnel due to uncertainty with incubation times. Symptoms to look for in possible victims include headache, stiff neck, back pain, unsteady gait or fever.
Evidence provided by the state health department showed that clinics had no way to know the NECC products were contaminated.
Diana Reed, 56, of Brentwood, who had been hospitalized with the illness, died Wednesday. She has been identified as the third victim in Tennessee.
The Tennessean reported Friday that Kentucky judge Eddie C. Lovelace was likely the first victim. Lovelace died Sept. 17 at Vanderbilt University Medical Center.
The newspaper also reported Thomas Warren Rybinski, 55, of Smyrna, died of aspergillus meningitis Sept. 29 at Vanderbilt.
Deaths have also been reported in Virginia and Maryland. All received steroid injections used mostly for back pain that have been traced back to a specialty pharmacy in Massachusetts. The pharmacy issued a recall last week and has shut down operations.
The Centers for Disease Control confirmed Thursday there are now 47 cases nationally and additional cases are still expected.
The reported cases are in the following states:
In all, 23 states received one of the three lots of voluntarily recalled injections. Those states include California, Connecticut, Florida, Georgia, Idaho, Illinois, Maryland, Indiana, Michigan, Minnesota, North Carolina, Nevada, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Virginia, West Virginia and Texas.
Doctors are being encouraged to discontinue use of all products produced by New England Compounding Center. There will be an expanded recall of more of their products.
The Food and Drug Administration inspected NECC on Oct. 1. Investigators found foreign particulate matter in an unopened vial.
Patients who received other types of injections with the affected methylpredisnolone acetate could be at risk. This includes injections other than epidurals.
Doctors said patients should look for redness and warmth at the injection site.
If patients are identified early, anti-fungal therapy can help avert the most "unfortunate consequences," said the CDC.
It's unclear if the drugs were actually made at the facility in Massachusetts.
More cases still possible
State officials said again Friday it is "certainly anticipating more cases." The condition of the affected patients run the spectrum - some are doing well, some are seriously ill and may die.
One of the new cases was from someone who received an epidural injection at the Specialty Surgery Center in Crossville.
This particular type of meningitis is not contagious and cannot be caught from person-to-person contact. This type is caused by a fungus often found in leaf mold.
Vandy doctor alerts health officials
A Nashville doctor is being credited for alerting health officials about a rare case of meningitis that has affected Tennessee and five other states.
Dr. April Petit, an infectious disease specialist at Vanderbilt, found the unusual case of meningitis in one of her patients and alerted the State Health Department in Tennessee.
The problem first stemmed from Saint Thomas Outpatient Neurosurgery Center, an outpatient surgical center/pain management clinic in Nashville.
The impacted patients include those ages 49 to 89 and now includes a clinic in Oak Ridge, TN, called PCA Pain Care Center.
The incubation period for this condition is two to 28 days, meaning some people who could be impacted may not yet be showing symptoms.
The state is now concerned about patients who received epidural injections as far back as July 1. Saint Thomas is now notifying patients who got injections back to that date. However, none of the new cases identified Wednesday are within that new window.
Health officials said Wednesday they are expanding the timeline of concern to ensure it doesn't miss any cases, but they don't have any reason to believe there are more.
Patients of Saint Thomas Outpatient Neurosurgery Center who had lumbar epidural steroid injections between July 30 and Sept. 20 may have contracted a fungal meningitis.
The facility was closed Sept. 20, and all 700 patients who received those injections have been notified, officials said.
Fungal meningitis can be especially difficult to diagnose, and worse yet it can be tough to treat.
"Since this is all quite new, it is difficult to predict how successful the treatment will be," said Dr. William Schaffner, with Vanderbilt University Medical Center. "It's not an easy infection to treat. It's new. Fungal infections, traditionally, are not so easy to treat."
"Early identification is very important. And we believe the earlier the people are identified and treatment begins, the better outcome they're likely to have," Dreyzehner said.
The mere mention of an epidural may have some wondering if pregnant women and new mothers should be worried, but experts said not at all.
"There is no risk to anyone who did not have an epidural steroid injection," Schaffner said. "This is not, for example, a risk for pregnant women who are getting epidural injections during labor and delivery."
The Saint Thomas clinic voluntarily shut down and will not reopen until the Tennessee Department of Health and CDC are confident the problems have been resolved.
If you have any questions or concerns, call the state health hotline at 1-800-222-1222.
Copyright WSMV 2012 (Meredith Corporation). All rights reserved. The Associated Press contributed to this report.