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13 Jan 2003

Source: New York Times, February 20, 2002.


Report Notes Swift Course of Inhalational Anthrax


Detailed descriptions of the swift and relentless course of inhalational anthrax, and of doctors' futile efforts to save two women whose symptoms were not diagnosed early enough, are being published today for the first time in The Journal of the American Medical Association.

Although the victims are not named, in keeping with the journal's tradition of protecting patient confidentiality, the descriptions match those of Kathy T. Nguyen, the 61- year-old hospital employee from the Bronx who died on Oct. 31, and Ottilie W. Lundgren, the 94-year-old woman from Oxford, Conn., who died on Nov. 21.

The journal also contains a case report on the 7-month-old boy who survived a life-threatening case of cutaneous anthrax that began in late September, presumably because he was exposed to spores in a visit to ABC-TV, where his mother worked and where spores were later detected.

All three reports were prepared by doctors who had treated the patients and helped investigate their cases.

In an editorial in the same issue of the journal, scientists from the Centers for Disease Control and Prevention write that "despite intensive investigations, the sources of their infection may never be known" and that Americans are still at risk for exposure to anthrax or other germ warfare agents.

Ms. Nguyen had been ill for three days before she was taken to Lenox Hill Hospital in Manhattan with weakness, shortness of breath, malaise, cough, chills and a feeling of heaviness in her chest. She had been coughing up pink-tinged secretions. Her X-ray showed a widened mediastinum, the area in the middle of the chest, a classic sign of inhalational anthrax.

She was given an oxygen mask and a drug used to treat heart failure. Doctors also gave her an antibiotic, "for the possibility of inhalational anthrax."

But within hours, Ms. Nguyen's breathing deteriorated, and she had to be put on a respirator. Her blood pressure dropped, a sign of shock. She was given more antibiotics, and other drugs to control her blood pressure. CT scans showed that the sac enclosing her lungs was filling with fluid, and she had hemorrhages in various tissues in her chest. Doctors drained about two quarts of fluid from her chest. She also had blood in the sac that encases the heart.

On Ms. Nguyen's second day in the hospital, her liver and kidneys began to fail, she needed transfusions, and her blood culture grew organisms that looked suspiciously like Bacillus anthracis.

On the third day, anthrax was confirmed, and her antibiotic was switched to Cipro. Her breathing continued to deteriorate, despite the respirator. Her heart was being compressed by the fluid that was accumulating around it; doctors tried but did not succeed at draining the fluid.

Ms. Nguyen continued to deteriorate. Her heart stopped, and doctors could not resuscitate her. She died on her fourth day in the hospital. Her death certificate listed the cause of death as inhalational anthrax, and the manner of death as homicide.

Ms. Lundgren was admitted to Griffin Hospital in Derby, Conn., on Nov. 16, with symptoms similar to Ms. Nguyen's: fever, aches and pains, a dry cough and shortness of breath. She, too, had been ill for about three days. Doctors tested her blood and urine but did not initially suspect anthrax, and she was not given antibiotics.

The next day, when bacteria were found in the blood culture, she was given Cipro and other antibiotics. Further tests were needed to find out which type of bacteria they were. On Nov. 19, tests on the blood culture suggested anthrax, and the hospital notified the state health department.

In the meantime, Ms. Lundgren's breathing worsened, and she needed a respirator. Her kidneys began to fail. More antibiotics and other drugs were added.

On Nov. 20, anthrax was confirmed by the state. Ms. Lundgren died the next day.

Ms. Lundgren's doctors note that she may have been unusually vulnerable because of her age and an underlying lung condition.

In the third case described in the journal, the 7-month-old baby developed a sore and severe swelling on his arm that did not improve when doctors gave him a penicillin-like antibiotic. He was admitted to New York University Hospital. Doctors treated the sore but did not culture it. They said they thought it might be a spider bite or bone infection.

On his second day in the hospital, the baby became feverish, and the center of the sore began to blacken. The baby developed hemorrhages on some parts of his skin.

Over the next few days, he became so anemic that he needed transfusions, and his kidney function began to deteriorate.

On his 12th day in the hospital, the first case of cutaneous anthrax in New York was reported. Two biopsies of the baby's skin lesion were performed the next day and sent with blood cultures to the C.D.C. Two days later, the tests were found to be positive. The baby was given Cipro, and his blood counts and kidney function gradually returned to normal, 30 days after he had been admitted to the hospital.

The doctors said his case had features that had never before been reported from patients with cutaneous anthrax, including the need for transfusions, the kidney problems and dangerous abnormalities in blood levels of sodium. Over all, they said, he had a severe systemic illness that was worse than cases of cutaneous anthrax that had previously been described in textbooks and journals. They warned that cutaneous anthrax could quickly turn into a dangerous illness and that doctors must consider it when they see unusual progressive skin inflammations. Such patients should be admitted to the hospital and given antibiotic treatment and careful monitoring of their blood counts and blood chemistry.