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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 14, a 56-year-old African-American woman who worked as a mail sorter in the Hamilton, New Jersey, US Postal Service facility, became ill with vomiting and diarrhea, followed the next day by subjective fever and chills unrelieved by aspirin. The vomiting and diarrhea improved, but over the next 2 days she had fevers to 38.4oC with shaking chills, headache and fatigue. A nonproductive cough developed, along with mild shortness of breath, and anterior chest pain on inspiration. She had no sore throat or rhinorrhea. Her past medical history included a transient ischemic attack. 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 19, because of persistent fever and worsening chest pain, she went to a local emergency room. Findings at that time included temperature 38.4oC, heart rate 120/min, blood pressure 159/95 mm Hg, and respiratory rate 18/min. She appeared ill with increased respiratory effort, had decreased breath sounds at both bases, and had a 0.5- to 1.0-cm healing scab on the anterior neck. Initial WBC was normal except for elevation in neutrophil band forms, and hematocrit and platelets were normal. Serum electrolytes, creatinine, and coagulation values were unremarkable, except for hyponatremia. Hepatic enzymes were elevated, and she was hypoxic (see Table - labeled Case 8 in article). A chest X-ray showed bibasilar infiltrates and a small right pleural effusion but no mediastinal widening. Initial differential diagnosis included atypical pneumonia versus inhalational anthrax, and the patient was begun on levofloxacin; rifampin was added the next day. Two days later, the fever persisted, dyspnea worsened, and large bilateral pleural effusions developed. Antibiotics were changed to ciprofloxacin, rifampin, and vancomycin. Right-sided thoracenteses were performed on October 21 and 22, and 750 cc and 650 cc of hemorrhagic fluid were removed, respectively.

On October 23, a right chest tube was placed. A chest CT on October 22 showed mediastinal and cervical lymphadenopathy, bibasilar infiltrates, and large left pleural effusion.

On October 25, the enlarging left sided effusion required chest tube placement.

On October 26, the fever resolved, transaminases became normal, and the dyspnea gradually improved.

On October 30 and November 1, the chest tubes were removed.

On November 5, the patient was discharged from the hospital. Blood for B. anthracis DNA by PCR was positive, as were immunohistochemistry studies for B. anthracis cell wall and capsule antigens from pleural fluid cytology preparations.

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