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 25, 2001, a 61-year-old Asian woman who worked in the supply room of a New York City Hospital had onset of malaise and myalgias. Over the next 2 days, she also had fatigue, chills, chest pain, progressively worsening dyspnea, and cough productive of sputum, which was later bloodtinged; she denied fever. She had a history of hypertension. 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 28, 2001, when she went a local hospital (other than her workplace), she was noted to be febrile in the emergency room and normotensive, but her heart rate was 110/min and respiratory rate 38/min, with room-air oxygen saturation of 92% by pulse oximetry. She was awake, alert, and completely oriented. She had prominent jugular venous distension at 60 degrees. Chest examination showed rales heard to the apices bilaterally. Abdominal and cardiovascular examinations were normal except for tachycardia, and she had no peripheral edema. WBC count was slightly elevated; hematocrit and platelets were normal. Serum chemistries and coagulation studies were normal except for hyponatremia, elevated hepatic enzymes, and hypoalbuminemia. The serum lactate dehydrogenase level was 1,370 IU/L. The patient required oxygen delivery by a nonrebreather mask to maintain adequate oxygenation (see Table - labeled Case 10 in article). Chest Xray was initially interpreted as showing pulmonary venous congestion with bilateral pleural effusions. Therapy for congestive heart failure was initiated, but an echocardiogram in the emergency department showed normal ejection fraction, no substantial wall motion abnormalities, and a small pericardial effusion. Therapy was changed to levofloxacin for atypical pneumonia. The patient's respiratory status worsened, and she was intubated. A CT scan of the chest showed mediastinal lymphadenopathy, massive mediastinal bleeding, thickened bronchial mucosa, and bilateral pleural effusions. Rifampin, gentamicin and subsequently nafcillin were added to her antimicrobial regimen.

Early on October 29, 2001, bilateral chest tubes were placed, and 2.5 liters of serosanguinous fluid was drained from the right side and 1.0 liter from the left (see above table). On the same day, bronchoscopy showed hemorrhagic mucosa throughout the entire tracheobronchial tree, friable and collapsible airways, and purulent secretions in multiple segments bilaterally.

On October 30, the antimicrobial regimen was changed to ciprofloxacin, rifampin, clindamycin, and ceftazidime. Serial echocardiograms documented enlarging pericardial effusion, ultimately with tamponade.

The patient's clinical condition progressively worsened, and she died on October 31, 2001, after attempted pericardiocentesis. Cultures of blood (after 20 hours) and pleural fluid grew B. anthracis. Autopsy findings included hemorrhagic mediastinitis; immunohistochemical stains confirmed the presence of B. anthracis in multiple organs.

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