NASHVILLE, Tenn. » Health officials say a rare meningitis outbreak has sickened 26 people in five states who received steroid injections for back pain. Four people have died.

Eighteen of the cases — and two deaths — are in Tennessee where a Nashville clinic received the largest shipment of the steroid suspected in the outbreak. A health official says the steroid came from a specialty pharmacy in Massachusetts.

According to the Centers for Disease Control and Prevention, the other cases are in Virginia, Maryland, Florida and North Carolina. Virginia and Maryland had one death each.

Health officials said Wednesday that more new cases are almost certain to appear in the coming days. Investigators have not ruled out contamination in other products.