Clinical manifestations and diagnosis of anthrax
- Kenneth H Wilson, MD
Kenneth H Wilson, MD
- Professor of Medicine, Division of Infectious Diseases
- Duke University Medical Center
Anthrax, caused by Bacillus anthracis, is an uncommon illness in the United States. From 1980 through 2000, only seven cases of anthrax were reported to the Centers for Disease Control and Prevention . In 2001, 22 confirmed or suspected cases of bioterrorism-related anthrax occurred in the United States, when B. anthracis spores in powder-containing envelopes were sent through the mail [2-4]. Subsequent sporadic cases have occurred rarely in the United States, such as in individuals exposed to contaminated animal hides while making traditional drums. (See "Microbiology, pathogenesis, and epidemiology of anthrax".)
The clinical manifestations and diagnosis of anthrax will be reviewed here. The pathogenesis, epidemiology, treatment, and prevention of anthrax are discussed separately. (See "Microbiology, pathogenesis, and epidemiology of anthrax" and "Treatment of anthrax" and "Prevention of anthrax".)
There are three major anthrax syndromes: cutaneous, inhalation, and gastrointestinal tract anthrax [5-7].
Cutaneous — Cutaneous anthrax is the most common form of the disease. Naturally occurring cases of cutaneous anthrax develop after spores of B. anthracis are introduced subcutaneously, often as a result of contact with infected animals or animal products. Cuts or abrasions increase susceptibility to cutaneous infection [8-10]. Spores vegetate and multiply, and the antiphagocytic capsule facilitates local spread. (See "Microbiology, pathogenesis, and epidemiology of anthrax".)
The incubation period is usually 5 to 7 days with a range of 1 to 12 days [11,12]. However, during an anthrax outbreak in Sverdlovsk, Union of Soviet Socialist Republics, cutaneous cases developed up to 13 days following the aerosol release of spores ; an outbreak in Algeria was reported with a median incubation period of 19 days .
- Hopkins RS, Jajosky RA, Hall PA, et al. Summary of notifiable diseases--United States, 2003. MMWR Morb Mortal Wkly Rep 2005; 52:1.
- Centers for Disease Control and Prevention (CDC). Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep 2001; 50:909.
- Centers for Disease Control and Prevention (CDC). Update: Investigation of bioterrorism-related anthrax--Connecticut, 2001. MMWR Morb Mortal Wkly Rep 2001; 50:1077.
- Bush LM, Abrams BH, Beall A, Johnson CC. Index case of fatal inhalational anthrax due to bioterrorism in the United States. N Engl J Med 2001; 345:1607.
- LaForce FM. Anthrax. Clin Infect Dis 1994; 19:1009.
- Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl J Med 1999; 341:815.
- Swartz MN. Recognition and management of anthrax--an update. N Engl J Med 2001; 345:1621.
- Wenner KA, Kenner JR. Anthrax. Dermatol Clin 2004; 22:247.
- Inglesby TV, O'Toole T, Henderson DA, et al. Anthrax as a biological weapon, 2002: updated recommendations for management. JAMA 2002; 287:2236.
- Pile JC, Malone JD, Eitzen EM, Friedlander AM. Anthrax as a potential biological warfare agent. Arch Intern Med 1998; 158:429.
- Brachman P, Kaufmann A. Anthrax. In: Bacterial infections of Humans: Epidemiology and Control, 3rd ed, Evans A, Brachman P (Eds), Plenum Publishing, New York 1998. p.95.
- Carucci JA, McGovern TW, Norton SA, et al. Cutaneous anthrax management algorithm. J Am Acad Dermatol 2002; 47:766.
- Meselson M, Guillemin J, Hugh-Jones M, et al. The Sverdlovsk anthrax outbreak of 1979. Science 1994; 266:1202.
- Abdenour D, Larouze B, Dalichaouche M, Aouati M. Familial occurrence of anthrax in Eastern Algeria. J Infect Dis 1987; 155:1083.
- Freedman A, Afonja O, Chang MW, et al. Cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant. JAMA 2002; 287:869.
- Quinn CP, Turnbull PCB. Anthrax. In: Topley and Wilson's Microbiology and Microbial Infection, 9th ed, Hausler WJ, Sussman M (Eds), Edward Arnold, London 1998. p.799.
- DRUETT HA, HENDERSON DW, PACKMAN L, PEACOCK S. Studies on respiratory infection. I. The influence of particle size on respiratory infection with anthrax spores. J Hyg (Lond) 1953; 51:359.
- Abramova FA, Grinberg LM, Yampolskaya OV, Walker DH. Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979. Proc Natl Acad Sci U S A 1993; 90:2291.
- Brachman PS. Inhalation anthrax. Ann N Y Acad Sci 1980; 353:83.
- Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis 2002; 8:1019.
- Jernigan JA, Stephens DS, Ashford DA, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis 2001; 7:933.
- HENDERSON DW, PEACOCK S, BELTON FC. Observations on the prophylaxis of experimental pulmonary anthrax in the monkey. J Hyg (Lond) 1956; 54:28.
- Friedlander AM, Welkos SL, Pitt ML, et al. Postexposure prophylaxis against experimental inhalation anthrax. J Infect Dis 1993; 167:1239.
- PLOTKIN SA, BRACHMAN PS, UTELL M, et al. An epidemic of inhalation anthrax, the first in the twentieth century. I. Clinical features. Am J Med 1960; 29:992.
- Borio L, Frank D, Mani V, et al. Death due to bioterrorism-related inhalational anthrax: report of 2 patients. JAMA 2001; 286:2554.
- Holty JE, Bravata DM, Liu H, et al. Systematic review: a century of inhalational anthrax cases from 1900 to 2005. Ann Intern Med 2006; 144:270.
- Kyriacou DN, Stein AC, Yarnold PR, et al. Clinical predictors of bioterrorism-related inhalational anthrax. Lancet 2004; 364:449.
- Centers for Disease Control and Prevention (CDC). Update: Investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR Morb Mortal Wkly Rep 2001; 50:941.
- Barakat LA, Quentzel HL, Jernigan JA, et al. Fatal inhalational anthrax in a 94-year-old Connecticut woman. JAMA 2002; 287:863.
- Beatty ME, Ashford DA, Griffin PM, et al. Gastrointestinal anthrax: review of the literature. Arch Intern Med 2003; 163:2527.
- Kanafani ZA, Ghossain A, Sharara AI, et al. Endemic gastrointestinal anthrax in 1960s Lebanon: clinical manifestations and surgical findings. Emerg Infect Dis 2003; 9:520.
- Sirisanthana T, Brown AE. Anthrax of the gastrointestinal tract. Emerg Infect Dis 2002; 8:649.
- Sirisanthana T, Navachareon N, Tharavichitkul P, et al. Outbreak of oral-oropharyngeal anthrax: an unusual manifestation of human infection with Bacillus anthracis. Am J Trop Med Hyg 1984; 33:144.
- Lanska DJ. Anthrax meningoencephalitis. Neurology 2002; 59:327.
- Health Protection Scotland. An outbreak of anthrax among drug users in Scotland, December 2009 to December 2010. A report on behalf of the National Anthrax Outbreak Control Team. http://www.documents.hps.scot.nhs.uk/giz/anthrax-outbreak/anthrax-outbreak-report-2011-12.pdf (Accessed on January 16, 2012).
- Morse SA, Kellogg RB, Perry S, et al. Detecting Biothreat Agents: the Laboratory Response Network. ASM News 2003; 69:433.
- Guarner J, Jernigan JA, Shieh WJ, et al. Pathology and pathogenesis of bioterrorism-related inhalational anthrax. Am J Pathol 2003; 163:701.
- Shieh WJ, Guarner J, Paddock C, et al. The critical role of pathology in the investigation of bioterrorism-related cutaneous anthrax. Am J Pathol 2003; 163:1901.
- Hoffmaster AR, Meyer RF, Bowen MD, et al. Evaluation and validation of a real-time polymerase chain reaction assay for rapid identification of Bacillus anthracis. Emerg Infect Dis 2002; 8:1178.
- Quinn CP, Semenova VA, Elie CM, et al. Specific, sensitive, and quantitative enzyme-linked immunosorbent assay for human immunoglobulin G antibodies to anthrax toxin protective antigen. Emerg Infect Dis 2002; 8:1103.
- Immunetics I. Immunetics Quick ELISA Anthrax - PA diagnostic test kit. Boston, MA 2004.
- Pilo P, Frey J. Bacillus anthracis: molecular taxonomy, population genetics, phylogeny and patho-evolution. Infect Genet Evol 2011; 11:1218.
- Price EP, Seymour ML, Sarovich DS, et al. Molecular epidemiologic investigation of an anthrax outbreak among heroin users, Europe. Emerg Infect Dis 2012; 18:1307.
- Rasko DA, Worsham PL, Abshire TG, et al. Bacillus anthracis comparative genome analysis in support of the Amerithrax investigation. Proc Natl Acad Sci U S A 2011; 108:5027.
- Centers for Disease Control and Prevention (CDC). Update: Investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR Morb Mortal Wkly Rep 2001; 50:889.
- Hupert N, Bearman GM, Mushlin AI, Callahan MA. Accuracy of screening for inhalational anthrax after a bioterrorist attack. Ann Intern Med 2003; 139:337.
- Sirisanthana T, Nelson KE, Ezzell JW, Abshire TG. Serological studies of patients with cutaneous and oral-oropharyngeal anthrax from northern Thailand. Am J Trop Med Hyg 1988; 39:575.
- CLINICAL MANIFESTATIONS
- Gastrointestinal tract
- Outbreak in heroin users
- Criteria for diagnosis
- Laboratory Response Network
- Specimen collection and transport
- DIAGNOSTIC APPROACH BY CLINICAL SYNDROME
- Inhalation anthrax
- - Distinction from common respiratory infections
- - Approach to testing
- Cutaneous anthrax
- Gastrointestinal tract anthrax
- SOCIETY GUIDELINE LINKS
- Clinical manifestations