Anthrax

1
Anthrax

• James Richardson, M.D.
• Ind. U. School of Medicine
• Ind. State Dept. of Health

2
History of Anthrax

• Woolsorters disease in England
• Ragpickers disease in Germany
• Last US case resulting in death 1976
• Endemic in Texas and Dakotas

3
Inhalation Anthrax

• Symptoms Fever, sweats, dry cough, nausea
• Hypotention
• CXR Normal or mediastinum widened or pleural
  effusion(s)
• Blood cultures positive in 6-12 hours

4
Inhalation Anthrax through 10 cases

• Incubation period 4-6 days
• Symptoms Fever, chills, sweats, fatigue, minimal
  or nonproductive cough, dyspnea, nausea and
  vomiting

5
Laboratory values in 10 cases of Anthrax

• WBC 9,800 with polys and bands
• Elevated hematocrit (10/10)
• Increased transaminases (9/10)
• Hypoxia (6/10)

6
Radiographic Findings in Anthrax cases

• Infiltrates (7/10)
• Pleural effusions (8/10)
• Mediastinal widening (7/10)
• CT of chest demonstrating LAN (7/8)

7
Anthrax Pathogenesis

• Incubation 3-60 days
• Spores phagocytized by Macrophages, transported
  to LN in mediastinum where they germinate causing
  a hemorrhagic mediastinitis
• Bacteremia and Meningitis follow

8
GI Anthrax

• Oropharynx or iliocecal region
• Oral Mucosal ulcer, regional LAN, neck edema
• GI Acute abdomen, hemorrhagic ascites, bloody
  diarrhea, cholera-like syndrome

9
Cutaneous Anthrax

• Painless pruritic papule
• Occurs 3-10 days after inoculation
• Lesion ulcerates and drains clear fluid first,
  then eschar forms
• Painful LAN may last for months

10
Identification of Anthrax

• Blood or tissue culture
• gamma phage lysis
• Direct fluorescent antibody to capsule or
  cell-wall antigens
• B.anthracis specific PCR
• Immunohistochemical and serologic (IgG) to
  protective Ag

11
Anthrax Treatment

• Cipro 500mg bid X 60 days
• Doxycycline 100mg bid X 60 d
• Amoxil 80mg/kg/d X 60 days
• Resistant to Ceftriaxone
• Cultures become negative 24 hours after starting
  therapy
• Infection not always immunogenic

12
Post exposure Prophylaxis for Anthrax

• 60 days of therapy
• Any quinolone (Cipro, Levaquin, Ofloxacin,
  Tequin) will work
• Doxycycline

13
Anthrax Case

• Sick for 3 days, still worked
• Collapsed at church
• ER WBC 13K, afeb, hypoT, CXR-neg, given fluids
  went home
• ER next day WBC 31K, GPR in CSF, hypoT, pleural
  effusion
• Despite pressors Vent support pt. went
  bradycardic and died

14
Anthrax, the bacteria

• Large, aerobic, GPR
• Life forms in wet alkaline soils
• Dry weather induces sporulation
• Spores last for decades
• Bacteria have two toxins Lethal toxin and Edema
  toxin
• Lives intra- and extracellularly

15
Summary Anthrax

• Anthrax presents as inhalation disease, GI (mouth
  and intestinal), and cutaneous
• Diagnosis relies upon culture, Antigen or DNA
  detection
• Nasal swabs have no role in screening patients

16
Summary Anthrax

• Early CXR findings normal Late CXR findings
  effusions, infiltrate, mediastinal widening
• Empiric therapy is key
• Any quinolone or doxycycline can be used
  empirically
• Treatment or post-exposure Prophylaxis is for 60
  days