NASHVILLE (AP) — Tennessee health officials are once again alerting patients who received tainted steroid shots after finding that some have infections at the injection site that could lead to fungal meningitis.

Tennessee Health Commissioner John Dreyzehner said Thursday that since Thanksgiving, officials have identified 22 new cases of these localized infections and one case of meningitis without a localized infection. Two patients with the injection-site infections also showed early signs of meningitis.

Dreyzehner said the infections are under the skin, so patients do not see them. Symptoms include increased pain at the injection site, numbness and possible loss of bowel and bladder control.

They can be hard to detect because the signs often are similar to the original symptoms that the patients sought steroid injections to treat - generally back pain and related problems.

"If we are not vigilant for these localized infections , we indeed could have a second wave of meningitis for some people," Dreyzehner said.

The localized infections include abscesses and arachnoiditis, an inflammation that can be extremely painful but not life-threatening by itself.

Dr. David Reagan, Tennessee's chief medical officer, said localized infections were found in many of the state's meningitis patients and health officials believe they are "likely part of the usual mechanism for causing meningitis in this outbreak."

What officials did not realize was how long those localized infections could linger.

"In some patients the localized infection stays localized for many weeks or even a few months before causing enough symptoms that lead to its detection," Reagan said.

Reagan and Dreyzehner said Tennessee has learned from the experience of Michigan, which began looking for localized infections early and has reported 120 of them, according to the Centers for Disease Control and Prevention websit e. That is by far the largest number of any of the 19 states affected by the outbreak.

Tennessee has identified 75 of these infections. In all, 107 Tennessee patients have developed either meningitis or local infections or both. Nationally, at least 560 people have been sickened and 36 have died. Thirteen of those deaths were in Tennessee.

Dreyzehner said health officials still do not know when people who received the contaminated steroid injections will be out of danger.

"That's why this is such a tragic and difficult situation," he said. "Imagine having to live with this."