UPDATE 1-More U.S. cases of meningitis confirmed in deadly outbreak

(Adds details of investigation, background)

By Tim Ghianni

NASHVILLE, Tenn., Oct 5 (Reuters) - Tennessee confirmed onFriday four more cases of rare fungal meningitis, as healthofficials in 23 states scrambled to notify thousands of patientswho received steroid injections linked to an outbreak that haskilled five people.

Three of the dead were in Tennessee, where the outbreakbegan, and one each in Virginia and Maryland. The four newillnesses in Tennessee brought to 29 confirmed cases in thatstate and a total of 39 in six states.

"It is imperative that we continue our efforts to protectTennesseans," Dr. John Dreyzehner, the state's healthcommissioner, told a news conference.

The steroid medication may have been administered topatients in 23 states, according to the U.S. Centers for DiseaseControl, raising concerns the number of cases will increase.

The steroid is usually injected to control back pain.While fungal meningitis is rare and life-threatening, it is notspread by person-to-person contact.

The infected patients have shown a variety of symptoms fromone to four weeks after their injection including fever, a newor worsening headache, nausea and new neurological deficits thatwould be consistent with deep brain stroke, the CDC said.

All the cases have so far been traced to three lots of thesteroid prepared at New England Compounding Center Inc inFramingham, Massachusetts. The company said it has suspended itsoperations while the investigation is ongoing.

The Massachusetts Health Department said there were 17,676vials of medication in each of the three lots ofmethylprednisolone acetate sent out July through September andhave a shelf life of 180 days.

The CDC said it had not yet determined the rate of infectionamong patients who received the potentially tainted steroid. Therate of infection is important because it would help pinpointthe scope of the potential outbreak.

In addition to Tennessee, four cases have been reported inVirginia, two in Florida, two in Maryland, one in North Carolinaand one in Indiana, the CDC said.

The steroid was sent to California, Connecticut, Florida,Georgia, Idaho, Illinois, Indiana, Maryland, Michigan,Minnesota, North Carolina, New Hampshire, New Jersey, Nevada,New York, Ohio, Pennsylvania, Rhode Island, South Carolina,Tennessee, Virginia, Texas and West Virginia, the CDC said.

Each state could have hundreds of patients or more who wereexposed through injections.

In Indiana, which had one case, St. Mary's Health said onThursday that 560 patients had received the medication at theSurgicare Cross Pointe clinic in Evansville.

Minnesota had no reported confirmed cases on Friday, but upto 600 patients may have been exposed to the tainted medication,state health department spokesman Buddy Ferguson said.

(Reporting by Tim Ghianni; Writing by David Bailey; Editing byGreg McCune and Philip Barbara)

((david.bailey@thomsonreuters.com)(312 371 4002))