NASHVILLE -- An outbreak of a rare and deadly form of meningitishas now sickened 26 people in five states who received steroidinjections, health officials said Wednesday. Four people have died.

Eighteenof the cases are in Tennessee where a Nashville clinic received thelargest shipment of the steroid suspected in the outbreak. The drug wasmade by a specialty pharmacy in Massachusetts that has since issued arecall.

Three cases have been reported in Virginia, two inMaryland, two in Florida and one in North Carolina. Two of the deathswere in Tennessee; Virginia and Maryland had one each, the Centers forDisease Control and Prevention said.

More new cases are almostcertain to appear in the coming days, said Tennessee Department ofHealth Commissioner John Dreyzehner. Cases in that state began in Julyand five new cases were confirmed over the past 24 hours, he saidWednesday.

Investigators have been looking into at least threedifferent products used for the back injections that could have beentainted by the fungus that appears to be behind the illnesses. None ofthe products have been ruled out. However, the primary suspicion is onsteroid medication, which is commonly used for back pain.

The Foodand Drug Administration identified the maker of the steroid as the NewEngland Compounding Center, a specialty pharmacy in Framingham, Mass.Last week, the company issued a recall of three lots of the steroid.Company officials could not be immediately reached Wednesday afternoonby telephone; the company's website was unavailable.

An infectiousdiseases specialist at Vanderbilt University says he believes thecountry will see more cases in the upcoming weeks.

Dr. WilliamSchaffner chairs Vanderbilt's Department of Preventive Medicine. He hasbeen following the investigation into the cause of the infection sinceit was first detected in a patient at the university's hospital abouttwo weeks ago.

Schaffner said he believes part of the reason for the Nashville cluster is early detection.