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Inhalation Anthrax: Clinical Features of Bioterrorism-Related Cases

Two articles in JAMA describe the clinical features of inhalation anthrax in 4 patients (2 of whom died) and advance our understanding of this disease when it is induced by bioterrorism. All 4 patients were postal workers, aged 47 to 56, who worked in the Brentwood mail facility in Washington, D.C., that processed anthrax-contaminated mail.

The 2 surviving patients each presented with 3 days of prodromal symptoms: low-grade fever, chills, cough, dyspnea on exertion, mild sore throat, and malaise in 1 patient; and worsening headache, nausea, chills, night sweats, and mild sore throat -- without respiratory symptoms -- in the other. Upon hospitalization, both patients had low-grade fever, tachycardia, and abnormal chest X-rays demonstrating a widened mediastinum, bilateral hilar masses, pulmonary infiltrates, and pleural effusions. Non-contrast-enhanced chest CT exams in each patient revealed well-defined, profuse mediastinal adenopathy. After receiving appropriate antimicrobial therapy, both patients recovered.

The 2 patients who died succumbed within 24 hours of hospitalization. One had 6 days of prodromal symptoms, primarily gastrointestinal, consisting of nausea, abdominal pain, vomiting, diaphoresis, and lightheadedness, with dyspnea developing only on the sixth day. The other had a 5-day prodrome, consisting predominantly of myalgias, malaise, weakness, and fever, with dyspnea also developing late. Upon hospitalization, both patients had retrosternal chest pressure and dyspnea, leading to respiratory failure that required mechanical ventilation. Both patients were also tachycardic and had leukocytosis and hemoconcentration. Chest X-rays in both patients revealed a widened mediastinum, pulmonary infiltrates, and pleural effusions, confirmed in 1 patient by non-contrast-enhanced chest CT exam. Both patients received appropriate antimicrobial therapy during hospitalization.

Comment: Clinical suspicion of inhalation anthrax now requires familiarity with up-to-date information on its bioterrorist epidemiology, which, in these cases, was linked to postal services. For updated epidemiologic information, clinicians should consult the CDC's bioterrorism Web page: http://www.bt.cdc.gov. Prompt diagnosis and antimicrobial therapy clearly increase survival rates in this devastating disease. Although some clinical features of inhalation anthrax may resemble those of influenza-like illness (ILI), there are important differences: Nasal congestion and rhinorrhea are common with ILI but rare with inhalation anthrax; dyspnea, nausea, and vomiting are uncommon with ILI and more common with inhalation anthrax; and characteristic chest X-ray abnormalities develop rapidly with inhalation anthrax.

— N Blacklow

Published in Journal Watch Infectious Diseases November 28, 2001

Citation(s):

Mayer TA et al. Clinical presentation of inhalational anthrax following bioterrorism exposure. Report of 2 surviving patients. JAMA 2001 Nov 28 286 2549-2553.

• Original article (Subscription may be required)
• Medline abstract (Free)

Borio L et al. Death due to bioterrorism-related inhalational anthrax. Report of 2 patients. JAMA 2001 Nov 28 286 2554-2559.

• Original article (Subscription may be required)
• Medline abstract (Free)

Lane HC and Fauci AS. Bioterrorism on the home front. A new challenge for American medicine. JAMA 2001 Nov 28 286 2595-2597.

• Original article (Subscription may be required)
• Medline abstract (Free)