Last Updated

08 Dec 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 2, 2001, a 63-year-old Caucasian photo editor working for a Florida newspaper awoke early with nausea, vomiting, and confusion and was taken to a local emergency room for evaluation.

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.

His illness, which started on September 27 during a trip to North Carolina, was characterized by malaise, fatigue, fever, chills, anorexia, and sweats. No history of headache, cough, chest pain, myalgias, dyspnea, abdominal pain, diarrhea, or skin lesions was reported. Past medical history included hypertension, cardiovascular disease, and gout. He did not smoke.

On admission, the patient was alert and interactive but spoke nonsensically. Temperature was 39.2^oC, heart rate 109/min, blood pressure and respiratory rate were normal. Initial pulmonary, heart, and abdominal examinations were reported as normal. No nuchal rigidity was observed. He was not oriented to person, place, or time. Admission laboratory values included a normal total white blood cell (WBC) count, but the platelet count was low. Serum chemistries were normal, except for borderline hyponatremia and elevated total bilirubin. He had mild metabolic acidosis (see Table  - labeled Case 1 in article).

A chest X-ray showed a prominent superior mediastinum, left perihilar edema or infiltrate, a small left pleural effusion, and cardiomegaly (see Figure below). Cerebrospinal fluid (CSF) analysis showed WBC count 4,750/microL (81% neutrophils), red blood cell count 1,375/microL, glucose 57 mg/dL (serum glucose 174 mg/dL), and protein 666 mg/dL.

Microscopy examination of the CSF showed many gram-positive bacilli (see Figure below). B. anthracis was isolated from CSF after 7 hours of incubation and from blood cultures within 24 hours of incubation.

The patient was admitted to the hospital with a diagnosis of meningitis. After a single dose of cefotaxime, he was started on multiple antibiotics, including ceftazidime, gentamicin, metronidazole, doxycycline, ampicillin, and trimethoprim-sulfamethoxazole. Shortly after admission, he had generalized seizures and was intubated for airway protection.

On hospital day 2, penicillin G, levofloxacin, and clindamycin were begun; ampicillin, ceftazidime, and trimethoprim-sulfamethoxazole were discontinued. He remained febrile and became unresponsive to deep stimuli. His condition progressively deteriorated, with hypotension and worsening renal insufficiency.

The patient died on October 5. Autopsy findings included hemorrhagic mediastinal lymphadenitis, and immunohistochemical staining showed disseminated B. anthracis in multiple organs.

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