Clinical details for Anthrax Case 13

On October 15, a 43-year-old South Asian woman, also a mail sorter at the US Postal Service facility in Hamilton but at different mail sorting machines from those used by the patient in Case 8 (Case 11), became ill. She had intermittent fevers with chills, dry cough with chest discomfort and shortness of breath, myalgias, and fatigue. She also had nausea and vomiting but no abdominal pain or diarrhea. She complained of "head stuffiness" but no rhinorrhea or sore throat. She also had headache and was reported to be mildly confused.

On October 16, when she visited her primary-care physician, she had a temperature of 37.8^oC and was started on levofloxacin for bronchitis. Her past medical history was unremarkable, and she did not smoke.

^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.

On October 18, she went to a local emergency room because of persistent symptoms. Vital signs were as follows: temperature 38.4^oC, heart rate 120/min, respiratory rate 16/min, and blood pressure 141/85mm Hg, with oxygen saturation 92% on room air and 97% on 4 L of oxygen by nasal cannula. She appeared ill and had decreased breath sounds with egophony at the right base. WBC showed increase in neutrophil band forms; hematocrit and platelet count were normal. She had hyponatremia, but electrolytes, renal function, and coagulation values were otherwise normal. Hepatic enzymes were elevated (see Table - labeled Case 9 in article). Blood PCR for B. anthracis DNA obtained 2 days after initiation of antibiotics was negative. A chest X-ray showed right hilar opacity consistent with consolidation or mass, moderate right and minimal left pleural effusions. Antibiotics were changed to azithromycin and ciprofloxacin. Ciprofloxacin was discontinued 24 hours later.

On October 19, a chest CT showed increased soft tissue in the mediastinum (thought to represent adenopathy), right hilar consolidation with possible underlying mass, and large right pleural effusion. Clindamycin and ceftriaxone were added, and thoracentesis was performed with removal of 500 cc of serosanguinous fluid (see above Table). Pleural fluid cytology preparation was positive for B. anthracis cell wall and capsule antigens by immunohistochemical staining.

On October 21, repeat thoracentesis was required, and 800 cc of fluid was removed. On October 22, bronchoscopy found edematous, erythematous mucosa. A transbronchial biopsy showed B. anthracis cell wall and capsule antigens by immunohistochemical staining. Cultures of endobronchial samples, pleural fluid, and a nasal swab were all negative for B. anthracis, and no other pathogens were identified.

On October 23, the fever resolved, other symptoms began to improve, treatment was changed to doxycycline, and the patient was discharged from the hospital on doxycycline.


CLINICAL DETAILS FOR ANTHRAX CASE 13