Two more patients have died of rare fungal meningitis, bringing the death toll Saturday in the multi-state outbreak to 23.

U.S. federal health officials say the number of confirmed cases has climbed to at least 281 in 16 states. Tennessee leads the list of cases with 69.

But officials believe as many as 14,000 people in 23 states were injected with a contaminated steroid to treat back or joint pain.

The now-closed New England Compounding Center produced the medicine which was tainted with a fungus. Federal officials are investigating the center for allegedly making large doses of a drug. The pharmacy was licensed only to produce small batches of made-to-order prescriptions.

A number of victims and their families plan to file lawsuits against the facility.

Meningitis is a disease infecting the membranes protecting the brain and spinal cord. Fungal meningitis is the rarest form of the disease. Others are caused by bacteria, a virus, or a parasite.