ANTHRAX

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ANTHRAX

• Humberto Guerra
• Instituto de Medicina Tropical
• Alexander von Humboldt
• UNIVERSIDAD PERUANACAYETANO HEREDIA

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ANTHRAX

• - Etiologic agent Bacillus anthracis Cohn 1875.
• - Large (8 x 1.2 mm) Gram positive, nonmotile,
• weakly hæmolytic central spores, straight
  ends,
• encapsulated in vivo, produces long chains.
• - Pathogenic to herbivores, man, lab animals.
• - Habitat Parasitic persists in cursed
  fields.
• - Sporulation only in aerobic conditions.
• - Capsule antigen poly D-glutamic acid g-peptide
• - Immunogenic protein toxin, edematizing, lethal.

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Bacillus anthracis culture
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(blue)
(red)
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B. anthracis on Blood Agar
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Bacillus anthracis in a lesion
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Bacilli
Inflammatory cells
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Lymph node necrosis, large bacilli
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STAGES OF INFECTION

• Encounter organism and body surfaces
• Adhesion generalized and receptor-specific
• Initial multiplication ? in situ colonization
• Invasion ? breaching of anatomic barriers
• Lymphatic stage ? invasion of bloodstream
• Generalized infection, metastases ? local
  colonizations, tropisms of certain organisms.

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Natural history of Anthrax

• Encounter defines disease type and outcome
• Herbivores Spores germinate, are eaten, and oral
  lesions or abrasions mediate ? blood invasion
• Man Spores in wool, hair, hide ? skin or lung
  Vegetative forms in meat ? bowel lesions
• Adhesion spores or vegetative forms stick to
  tissues and multiply until they breach anatomic
  barriers
• Invasion first local, then lymphatic,
  and later
• Generalized infection ? leading to death.

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Malignant pustule

• Anthrax proper, Charbon
• In endemic areas, through contact with infected
  animals
• In industry, contact with hides, bones, wool,
  hair
• Occasionally, brushes, bone, ivory, clothes,etc.
• History in days incubation of 3 to 4 days
  then,
• 1) Initial pimple or papule, single or multiple
• 2) Vesicle ring around papule - initially, clear
  fluid
• 3) Papule ulcerates, dries, becomes dark eschar
• 3) Edema develops, becomes angry red
• 3-on) No local pain, but local ganglia grow
  tender
• 4) Eschar blackens, grows on vesicles, thickens

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Ulcerandvesiclering
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Black eschar.Rednessremains
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Site of Malignant pustule

• Head usually no complication
• Face severe, superinfection gangrene near eye
• Neck, breast or chest wall massive edema, over
  thorax and sometimes involving scrotum
• Shoulders, arms may be multiple, small lesions
• Forearms, fingers atypical on palms
• General symptoms, fever, chills, depend on site.
  
• Weakness, hypotension are danger signs.

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Notice the edema and typical lesions
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Very localized thumb lesion.Tough
subcutaneoustissues limitthe lesion
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Notice small finger ulcer, but large edema and
erythema
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The forehead lesion is minimal. This could be due
to the localization or to a previous state of
immunity
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Taken from the AFIP Atlas
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Pulmonary Anthrax

• Aspiration anthrax - Requires high inoculum
• - Man resists over 2,000 inhaled spores/day .
• Onset abrupt - The patient is acutely ill in
  hours
• fever, dyspnea, cyanosis, rales, tachycardia,
  feeble
• pulse, hypotension. Vomiting, sweating, anxiety.
  
• Death in 2 or 3 days if untreated.
• Lesions in mediastinal lymph nodes, carried there
  by alveolar macrophages, causing edema, toxemia,
  bacteremia.

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Woolsorters Disease (AFIP)
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THE SVERDLOVSK ANTHRAX OUTBREAK

• An outbreak of anthrax occurred during April,
  1979, among people who lived or worked in a
  narrow zone downwind of a Soviet military
  microbiology facility in Sverdlovsk (now
  Ekaterinburg) Russia. In addition, livestock died
  of anthrax within a larger downwind zone. The
  facility was suspected by western intelligence of
  being a biological warfare research facility.
  Intelligence analysts attributed the outbreak to
  the accidental airborne release of anthrax
  spores. The Soviets maintained that the outbreak
  was de to ingestión of contaminated meat
  purchased on the black market. Finally, in 1992,
  President Yeltsin of Russia admitted that the
  facility had been part of an offensive biological
  weapons program, and that the disease in animals
  and people resulted from an accidental release of
  anthrax spores.

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Gastric and Intestinal Anthrax

• Acute gastro-enteritis, abdominal pain,
  prostration.
• Often fatal.
• Intestinal lesions edematous, with black eschar -
  
• obstruction, enlarged, hemorrhagic mesenteric
  lymph nodes.

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Cecal Lesion from eating undercooked Carabao...
(AFIP)
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Anthrax Meningitis

• Usually a complication of anthrax septicemia.
• Subarachnoid haemorrhage is a common feature
• Very often fatal

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Anthrax meningitis Subarachnoid Haemorrhage
(AFIP)
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Anthrax - Disease in animals

• Fulminating, acute, subacute or chronic.
• Apoplectic death fall - animals found dead.
• Acute excitable, then depressed, cardiac and
• respiratory distress, trembling, staggering,
  convulsions.
• Edematous lesions, blood exudes, incoagulable.
• Death in 1-2 days, or 4-5.
• Chronic infection in more resistant animals
  pigs.

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The inoculated mouse is jumpy, its hair is
raised, its tail stiff , and has an unsure gait
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Theres fluid in the peritoneal cavity ascitis
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Organs are edematous, spleen is black and
congested
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Prevention

• Control in animals. Annual vaccination protects.
• Disposal of animal carcasses disinfect with oil,
  burn, bury deep, covered with quicklime.
• Spores will NOT form inside the carcass, and
  putrefaction kills the Bacillus. Flies feeding
  on incoagulable blood may be a problem.

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Global Health NetworkEpidemiology Supercourse
Zoonoses
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An anthrax site near the road. Notice the
epidemiology team, recently obtained skin
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A more remote anthrax site (2 slides)
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A typical cowgirl. Notice building
materials, number of different animals
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Global Health NetworkEpidemiology Supercourse
Zoonoses
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Prevention

• Control in animals. Annual vaccination protects.
• Disposal of animal carcasses disinfect with oil,
  burn, bury deep, covered with quicklime.
• Spores will NOT form inside the carcass, and
  putrefaction kills the Bacillus. Flies feeding
  on incoagulable blood may be a problem.

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Veterinary Dr. vaccinating in an anthrax site
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An anthrax death. Notice flies feeding on blood
and secretions
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A community asset empiric vet couple.
Notice vaccine ampule on chair
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Burning a carcass in a hole... Not deep enough
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Prevention

• Industrial protection. Gloves, masks,
  disinfection of materials prior to handling.
  Mostly impractical!
• Information, charts, education for awareness.
• Reporting of sudden illness in risk areas,
  lesions.

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Diagnosis

• High suspicion level - Inquire on dead or sick
  cattle-
• Examine papules/lesions scrape, prepare Gram
  stain, culture.
• If needed, blood culture or CNS culture.

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Treatment

• Penicillin continues to be the treatment of
  choice.
• iv treatment was adopted to provide enough.
• Do not incise lesions.
• Eschar is not dangerous after treatment.
• The patient must remain hospitalized until fully
  cured.

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BIOTERRORISM

• How real is it?
• Well, there WERE some bacteria prepared for
  biological warfare...
• Anthrax was a first choice!

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EMERGING INFECTIOUS DISEASESVol 4 No 5
July-August 1999

• Special Issue
• The Threat of Biological Attack Why Concern Now?
  
• David W. SiegristPotomac Institute for Policy
  Studies, Arlington, Virginia, USA
• For a biological attack to occur, three elements
  must be in place a vulnerable target, a person
  or group with the capability to attack, and the
  intent (by the perpetrator) to carry out such an
  attack.

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Category A Biological Weapons(Recommendations of
the CDC Strategic Planning Workgroup, MMWR, April
21, 2000 / 49(RR04)1-14)

• High-priority agents include organisms that pose
  a risk to national security because they
• can be easily disseminated or transmitted
  person-to-person
• cause high mortality, with potential for major
  public health impact
• might cause public panic and social disruption
  and
• require special action for public health
  preparedness

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Category A agents include

• Variola major (smallpox)
• Bacteria Bacillus anthracis (anthrax) Yersinia
  pestis (plague) Clostridium botulinum toxin
  (botulism) Francisella tularensis (tularaemia)
• Filoviruses Ebola hemorrhagic fever, Marburg
  hemorrhagic fever and
• Arenaviruses Lassa (Lassa fever), Junín
  (Argentine hemorrhagic fever) and related
  viruses.

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EMERGING INFECTIOUS DISEASES ARTICLE
(CONTINUING)The United States is unprepared to
deal with a biological attack. (other nations
also) Over the past several years, preparedness
strides have been made, especially in the largest
cities. However, much of the needed equipment is
not available. Pathogen sensors are not in place
to detect that a biological attack has taken
place. New medicines are needed.
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In combating terrorist attacks, treatment is a
more practical approach than prevention yet many
biological agents are extremely difficult to
treat with existing medicines once the symptoms
appear. In addition, many of the most important
prophylactic drugs have limited shelf lives and
cannot be stockpiled. Moreover, their
effectiveness could be compromised by a
sophisticated attacker.
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SOOOOO................

• Its clear a vaccine for human use (BOTH FOR
  MILITARY AND CIVILIAN PERSONNEL) is needed.....

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• The Schedule (for the U.S.A. Armed Forces)
• May 18, 1998 Secretary of Defense William Cohen
  approved the vaccination plan based on the
  successful completion of all testing and
  operational criteria
• Between now and about 2005, the entire force,
  including all new service member will begin
  receiving the six-shot series of the anthrax
  vaccination in a phased immunization program

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The first three shots are given in two-week
intervals. The following three shots are
administered at 6, 12, and 18 months. The program
also includes an annual booster