Last Updated

19 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 16, a 56-year-old African-American male US Postal Service mail sorter noted low-grade fever, chills, sore throat, headache, and malaise. This was followed by minimal dry cough, chest heaviness, shortness of breath, night sweats, nausea, and vomiting.

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 19, when he arrived at a local hospital, he was afebrile and normotensive. Heart rate was 110/min, and he was not tachypneic. He was in no acute distress but had decreased breath sounds and rhonchi at the left base. No skin lesions were observed. His past medical history was unremarkable, and he did not smoke. Total WBC count was normal, but there was a slight left shift in the differential. Hepatic transaminase levels and bilirubin were elevated. Serum albumin was decreased, but serum chemistries and renal function were normal. Arterial blood gas values showed adequate oxygenation (see Table - labeled Case 3 in article). A chest X-ray showed a widened mediastinum (especially in the right paratracheal region), bilateral hilar masses, bilateral pleural effusions, and a small right lower lobe air space opacity. CT of the chest showed diffuse mediastinal edema; marked paratracheal, subcarinal, hilar, and azygo-esophageal recess adenopathy (the largest node measuring 4.2 cm in diameter); and bilateral moderate pleural effusions. Within 12 hours, admission blood cultures grew B. anthracis. Ciprofloxacin, rifampin, and clindamycin were initiated.

On October 21, the patient had respiratory distress, which was treated with diuretics, systemic corticosteroids, and a therapeutic thoracentesis. During the course of hospitalization, the pleural effusion reaccumulated, necessitating two additional thoracenteses. All three pleural fluid specimens were hemorrhagic. The patient did not require intubation. Hematemesis developed, and several shallow gastric ulcers were noted on upper endoscopy.

On October 28, the patient had signs of hemolytic anemia and thrombocytopenia, which was treated with plasmapheresis. Hematologic values subsequently improved, and the patient remains hospitalized in stable condition.

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