Clinical details for Anthrax Case 20

On the evening of October 22, a 59-year-old Caucasian man, contract employee at a U.S. State Department mail sorting facility that received mail from the District of Columbia postal facility associated with cases 3 (Case 14), 4 (Case 17), 5 (Case 15), and 6 (Case 16), became ill. He had drenching sweats, followed over the next 2 days by fatigue, severe myalgias, subjective fever, chills, headache, nausea, vomiting, abdominal pain, cough with scant white sputum, and substernal chest pain. He had no dyspnea or diarrhea. His past medical history was unremarkable, and he 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.

When he arrived at a local emergency room on October 24, temperature was 38.2^oC, heart rate 116/min, and respiratory rate and blood pressure were normal. A complete blood count was normal, and serum electrolytes showed hyponatremia and hypokalemia (see Table - labeled Case 7 in article). A chest X-ray was initially reported as normal. The patient was thought to have a viral syndrome and was discharged, but blood cultures were obtained and ciprofloxacin was prescribed. He took one dose that night, but vomiting, fatigue, and headache worsened. He also reported transient distortion in his left visual field, and his wife reported that he was intermittently confused.

Blood cultures grew gram-positive bacilli after 17 hours of incubation; therefore, on October 25, he was called back to the hospital for admission. The blood isolate was subsequently identified as B. anthracis. At admission, his vital signs were as follows: temperature 38.2^oC, heart rate 108/min, respiratory rate 20/min, blood pressure 121/60 mm Hg, and oxygen saturation 94% on room air. He appeared ill and had decreased breath sounds at the right base. The rest of the examination was unremarkable. Laboratory studies on admission included WBC count 9,500/mm³ with 81% segmented neutrophils, 9% lymphocytes, and 9% monocytes, hematocrit 48.1%, platelet count 215,000/ mm³, normal electrolytes and creatinine, SGOT 85 IU/L, SGPT 64 IU/L, alkaline phosphatase 141 IU/L, bilirubin 1.6 mg/dL, and albumin 3.0 mg/dL.

On review, the initial chest X-ray showed mediastinal widening (see figure), and chest CT on the day of admission showed mediastinal adenopathy with evidence of hemorrhage, normal lung parenchyma, small bilateral pleural effusions, and a suspected small pericardial effusion (see figure below). Intravenous penicillin and rifampin were added to the ciprofloxacin.

His temperature rose to 39^oC. Over the next 24 hours, vancomycin was added and penicillin was discontinued.

On October 26, gastrointestinal bleeding developed, which required blood transfusion, endoscopic injection, and cautery of gastric and duodenal ulcers.

On October 27, atrial fibrillation with variable ventricular response developed. On October 28, fever reached a maximum of 39.4^oC and then decreased to 38.3^oC. On October 30, WBC peaked at 31,300/mm³.

On October 31, enlargement of the right pleural effusion required thoracentesis and removal of 900 cc of serosanguinous fluid (see above Table).


CLINICAL DETAILS FOR ANTHRAX CASE 20