Last Updated

31 Jan 2003

    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 55-year-old African-American man, a District of Columbia US Postal Service employee, became ill. He had fever, intermittent diaphoresis, myalgias, and cough productive of green sputum but no shortness of breath, chest discomfort, gastrointestinal symptoms, or headache.

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.

When he visited his primary-care provider on October 18, he had temperature of 38.9^oC, normal heart rate and blood pressure, and respiratory rate of 24/min. He had no other notable examination findings, but WBC count was slightly elevated (see Table - labeled Case 5 in article). His past medical history included diabetes mellitus and sarcoidosis. He did not smoke. No chest X-ray was performed. He was sent home with a diagnosis of a viral syndrome; no antibiotics were prescribed.

On October 21, he arrived at the emergency department with worsening symptoms, including chest tightness, fatigue, chills, myalgias, nausea, vomiting, and shortness of breath. Temperature was 38.9^oC, pulse 93 to 150/min and irregular, respiratory rate 20/min, and blood pressure 119/73 mm Hg. Signs of respiratory distress were observed. Examination findings included rales at the right base with diffuse wheezing and tachycardia. WBC count was 18,800/mm³ with a differential of 73% segmented neutrophils, 6% bands, 11% lymphocytes, and 8% monocytes. Hematocrit was 55%, and platelets were 141,000/mm³. Sodium was 130 mmol/L, potassium 5.3 mmol/L, chloride 99 mmol/L, and bicarbonate 14 mmol/L, with an anion gap of 17. Creatinine was 1.3 mg/dL, and glucose was 425 mg/dL. Aspartate aminotransferase (AST) was 76 IU/1 and alanine aminotransferase (ALT) was 77 IU/1. Coagulation studies were normal. Arterial pH was 7.42, PaC0₂ 25 mm Hg, Pa0₂ 66 mm Hg, and 0₂ saturation of 94% on 2 L of 02/min by nasal cannula. A chest X-ray showed right hilar and peritracheal soft tissue fullness with right middle and lower lobe infiltrates compatible with pneumonia and right pleural effusion. An electrocardiogram showed atrial fibrillation. The patient was intubated, ventilated, and administered levofloxacin, diltiazem, and insulin.

Later on the day of admission, the patient became hemodynamically unstable, had cardiac arrest, and died. Blood cultures grew B. anthracis. Autopsy findings included hemorrhagic mediastinal lymphadenitis, and immunohistochemical staining showed evidence of disseminated B. anthracis.

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