Last Updated

06 Nov 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 September 24, a 73-year-old Hispanic man, the newspaper mailroom clerk who delivered mail to the patient in Case 1 (Case 5), had onset of fatigue. On September 28, nonproductive cough, intermittent fever, rhinorrhea, and conjunctivitis developed. From September 28 to October 1, he had gradual progression of cough, marked worsening of fatigue with lethargy, onset of exertional dyspnea, fever, and sweats. He had mild abdominal pain associated with vomiting, and his co-workers and family noted intermittent periods of confusion. He had no underlying chronic illnesses, with the exception of a transient ischemic attack in August 2001. 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.

He was admitted to the hospital on October 1. Temperature was 38.5^oC, heart rate 109/min, respiratory rate 20/min, and blood pressure 77/49 mm Hg. He had bilateral conjunctival injection and bilateral pulmonary rhonchi. Examination, including assessment of neurologic function, was otherwise unremarkable. No skin lesions were observed. Admission laboratory results included normal WBC count and serum chemistries, except for increased serum creatinine, hypoalbuminemia, and elevated hepatic transaminases. Arterial blood gas values showed hypoxemia (see Table  - labeled Case 2 in article). Blood cultures obtained on hospital day 2, after initiation of antibiotics, showed no growth.

A chest X-ray showed left upper and lower lobe infiltrates consistent with pneumonia and a small left pleural effusion (see Figure below). No mediastinal widening was observed.

The patient was initially given intravenous azithromycin; cefotaxime and ciprofloxacin were subsequently added.

A nasal swab obtained on October 5 grew B. anthracis. Computed tomography (CT) of the chest showed bilateral effusions and multilobar pulmonary consolidation but no significant mediastinal lymphadenopathy (see Figure below).

A left thoracentesis yielded serosanguinous fluid (see Table above) positive for B. anthracis DNA by PCR. Bronchoscopy showed bloody secretions in the right lower lobe and left lung, with severe mucosal hyperemia, mottling, and inflammation. Bacterial cultures of bronchial washings and pleural fluid did not grow. A transbronchial biopsy showed B. anthracis capsule and cell wall by immunohistochemical staining. Tests for Legionella spp., acid-fast bacteria, Pneumocystis carinii, Chlamydia spp., Leptospira, and Hantavirus and other viral pathogens were negative. The hospital course included an episode of supraventricular tachycardia with hypotension, maximum WBC count 26,800/ mm3, and recurrent left pleural effusion that required repeat thoracentesis and placement of a chest tube. The pleural fluid from the second thoracentesis was positive for B. anthracis DNA by PCR. A pleural fluid cytology preparation and pleural biopsy showed B. anthracis capsule and cell wall by immunohistochemical staining. In addition, serial serum samples demonstrated a >4-fold rise in levels of serum antibody (IgG) to the PA component of the anthrax toxins by enzyme-linked immunosorbent assay (ELISA).

The patient's condition gradually improved, and he was discharged from the hospital October 17 on oral ciprofloxacin.

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