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On Friday, the Centers for Disease Control and Prevention (CDC) reported that the number of cases of a rare and deadly form of meningitis in the U.S. has risen to 47, which is an increase of 21 confirmed cases since Wednesday. Michigan and North Carolina reported a total of three additional cases since the CDC update, bringing up the total to 50.

As of Friday, there have been five deaths in the seven states have been affected by the fungal outbreak: Florida, Indiana, Maryland, Michigan, North Carolina, Tennessee, and Virginia. The CDC predicts that the disease will affect as many as 23 states.

Investigators suspect that the outbreak is a result of contamination of methylprednisolone acetate steroid injections that are usually administered to patients who suffer from back pain. A total of 17,676 vials containing the steroids in question had been previously recalled last week. The New England Compounding Center in Framingham, Mass., where the steroids were manufactured, has since shut down its operations.

Outbreaks, such as this, highlight the risks involved with compounding pharmacies. Unlike most other products, however, drugs from compounding pharmacies are often not approved by the Food and Drug Administration (FDA). Yet, hospitals and clinics will continue to use these products because of drug shortages in the U.S. that stem from delays and discontinuation, according to the FDA.

Signs of meningitis include nausea, vomiting, fever, neck pain, headaches, and neurological symptoms typically associated with strokes. According to the CDC, fungal meningitis is a non-transmissible from person to person, as opposed to bacterial and viral meningitis. However, because it is an airborne disease, inhaling fungal spores (which can be found in certain leaf molds) can result in infection as well.