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Last Updated

15 Nov 2002

    Source: Jernigan JA et al. Bioterrorism-Related Inhalation Anthrax: The First 10 Cases Reported in the United States, Emerging Infectious Diseases 7(6), Nov.-Dec., 2001.

On October 16, a 47-year-old African-American man, a US Postal Service employee who worked at the same District of Columbia mail distribution center associated with cases 4 (Case 17) and 5 (Case 15), had mild nonproductive cough, nausea, vomiting, and stomach cramps. On October 20, the patient had a syncopal episode at church but did not seek medical attention.

b WBC = white blood cells; WNL = within normal limits; ND = not done; NA = not available; SGOT = serum glutamic oxalacetic transaminase; SGPT = serum glutamic pyruvic transaminase; FiO2 = fractional inspired 02; RA = room air; NRBR = nonrebreathing mask; RBC = red blood cells;LDH = lactate dehydrogenase

c Pleural fluid studies were not performed at the time of the initial visit to a health-care provider.

Early in the morning of October 21, he arrived at an emergency department complaining of vomiting and profuse sweating. His past medical history included asthma and renal calculi. Therapy for asthma had not recently included corticosteroids. He was afebrile and had orthostatic hypotension. WBC count was slightly elevated, but he had normal serum chemistries and coagulation values. Serum glutamic pyruvic transaminase (SGPT) was slightly elevated (see Table - labeled Case 6 in article). A chest X-ray was initially read as normal, but later review noted an ill-defined area of increased density due to infiltrate or mass in the right suprahilar region. The patient was discharged after receiving intravenous hydration.

On the morning of October 22, he visited the emergency department again, reporting myalgias, chills, dyspnea, continued vomiting, and another syncopal episode. His temperature was 35.6oC, blood pressure 76/48 mm Hg, heart rate 152/min, and respiratory rate 32/min. He was ill-appearing with mottled skin that was cool to the touch, and he was in respiratory distress. He had bilateral wheezing, tachycardia, and mildly distended abdomen with absent bowel sounds. WBC count was 33,000/mm3 with a differential of 78% segmented neutrophils, 2% bands, 14% lymphocytes and 3% monocytes. Sodium was 148 mmol/L, bicarbonate 18 mmol/L, anion gap 21, and creatinine 2.8 mg/dL. Serum glutamic oxalacetic transaminase (SGOT) was 47 IU/L, SGPT 33 IU/L, and alkaline phosphatase 197 IU/L. Prothrombin time was 22.1 seconds and partial thromboplastin time was 96 seconds. Penicillin, ceftriaxone, rifampin, and levofloxacin were begun. Respiratory distress developed, which required endotracheal intubation and mechanical ventilation. Soon thereafter signs consistent with peritonitis were observed. Arterial pH was 7.13, PaC02 36 mm Hg, Pa02 106 mm Hg, and oxygen saturation 95% after intubation on 100% Fi02. A chest X-ray showed bilateral lung infiltrates concentrated within perihilar and infrahilar regions without pleural effusions. Chest and abdominal CT scans with intravenous contrast noted large bilateral pleural effusions, perihilar and suprahilar infiltrates, mediastinal edema, pneumomediastinum, ascites, air in the portal venous system, mesenteric edema, diffuse small bowel edema, and small collections of intramural air involving several parts of the jejunum. CT of the head was normal.

The patient died within 6 hours of admission. Gram-positive bacilli were visible on the peripheral blood smear, and blood cultures grew B. anthracis within 18 hours. Postmortem findings included prominent hemorrhagic mediastinal lymphadenitis and evidence of systemic B. anthracis infection by histopathologic and immunohistochemical tests.

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