Anthrax: Difference between revisions
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==Background== | ==Background== | ||
*Gram positive rod, Bacillus anthracis, which is capable of surviving inhospitable | *Gram positive rod, Bacillus anthracis, which is capable of surviving inhospitable conditions through the formation of endospores | ||
*Incubation period is 10 days with no ability for human to human transmission and therefore, no need for respiratory isolation | *Incubation period is 10 days with no ability for human to human transmission and therefore, no need for respiratory isolation | ||
**Though human to human transmission does not occur, potential harbors of spores (patient clothes) need to be isolated and decontaminated with 10% bleach<ref>Heninger SJ et al. Decontamination of Bacillus anthracis Spores: Evaluation of Various Disinfectants. Appl Biosaf. 2009 Jan 1; 14(1): 7–10.</ref> | |||
*In general there is cutaneous, inhalational, and gastrointesinal anthrax. | *In general there is cutaneous, inhalational, and gastrointesinal anthrax. | ||
===Inhalational=== | |||
==Clinical Features== | |||
[[File:Cutaneous anthrax lesion on the neck. PHIL 1934 lores.jpg|thumb|Cutaneous anthrax lesion on neck.]] | |||
[[File:Cutaneous_anthrax.png|thumb|Cutaneous anthrax]] | |||
[[File:Anthrax PHIL 2033.png|thumb|A skin lesion with black eschar characteristic of anthrax]] | |||
[[File:PMC3493280 1756-0500-5-464-1.png|thumb|Cutaneous anthrax with associated marked edema.]] | |||
[[File:PMC3291463 05-1407-F.png|thumb|Initial skin lesion with black eschar and red border. By the time the picture was taken, the massive associated edema of hand and arm had subsided.]] | |||
===Inhalational (5%)=== | |||
*Biphasic course | |||
====Prodrome Period==== | ====Prodrome Period==== | ||
*Early prodromal period often appears as an | *Early prodromal period often appears as an [[flu-like illness]] | ||
====Acute | *[[Fever]], dry [[cough]], [[myalgia]], malaise | ||
*Severe respiratory distress with symptoms consisting of: | *Transient clinical improvement followed by rapid decline | ||
**Hypoxia | |||
** | ====Acute phase==== | ||
** | *Severe [[respiratory distress]] with symptoms consisting of<ref>[http://emedicine.medscape.com/article/212127-overview Medscape: Anthrax]</ref>: | ||
**[[Hypoxia]], tachypnea, cyanosis | |||
**Severe dyspnea, chest pain | |||
**[[Shock]] | |||
**[[Mediastinitis]] | |||
===Cutaneous=== | ===Cutaneous (95%)=== | ||
*The disease will start as an area of | *The disease will start as an area of erythema and edema and progress to a vesicle which ruptures forming a central black eschar which eventually falls off | ||
*Total course of lesion evolution occurs over 1 week | *Total course of lesion evolution occurs over 1 week | ||
*Small minority of untreated patients develop rapidly fatal bacteremia <ref>Gordon, David. "Zoonotic Infections." Tintinalli's Emergency Medicine Manual, 8e Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH.</ref> | |||
===Gastrointestinal=== | ===Gastrointestinal=== | ||
*Over the course of 7 days, nonspecific abdominal pain, nausea and | *Over the course of 7 days, nonspecific [[abdominal pain]], [[nausea and vomiting]] with progress to severe abdominal pain, [[hematemesis|bloody emesis]] and [[diarrhea]] (usually bloody)<ref> CDC. Gastrointestinal anthrax after an animal-hide drumming event - New Hampshire and Massachusetts, 2009. MMWR Morb Mortal Wkly Rep. 2010 Jul 23;59(28):872-7. http://www.ncbi.nlm.nih.gov/pubmed/20651643</ref> | ||
*May present as oropharyngeal ulcers with [[dysphagia]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*[[Plague]] | *[[Plague]] | ||
*[[Glanders]] (Pseudomonas peudomallei) | *[[Glanders]] (Pseudomonas peudomallei) | ||
* | *[[Rickettsia]]l pox (Rickettsia akari) | ||
*Orf (parapox virus) | *Orf (parapox virus) | ||
*[[Staph]] [[lymphadenitis]] | *[[Staph]] [[lymphadenitis]] | ||
| Line 36: | Line 52: | ||
*Acute bacterial [[mediastinitis]] | *Acute bacterial [[mediastinitis]] | ||
*[[Mycoplasma]] | *[[Mycoplasma]] | ||
*[[Legionnaire's]] | *[[Legionella|Legionnaire's]] | ||
*[[Psittacosis]] | *[[Psittacosis]] | ||
*[[Tularemia]] | *[[Tularemia]] | ||
*[[Q fever]] (Coxiella burnetti) | *[[Q fever]] (Coxiella burnetti) | ||
*Viral pneumonia | *Viral [[pneumonia]] | ||
*[[Histoplasmosis]] | *[[Histoplasmosis]] | ||
*[[Coccidiomycosis]] | *[[Coccidiomycosis]] | ||
*Ruptured [[Aortic Dissection]] | *Ruptured [[Aortic Dissection]] | ||
*[[SVC syndrome]] | *[[SVC Syndrome|SVC syndrome]] | ||
*[[Silicosis]] | *[[Pneumoconiosis|Silicosis]] | ||
*[[Sarcoidosis]] | *[[Sarcoidosis]] | ||
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{{Bioterrorism agents}} | {{Bioterrorism agents}} | ||
== | ==Evaluation== | ||
CXR/CT | [[File:Anthrax - inhalational.jpg|thumb|[[CXR]] of inhalational anthrax showing mediastinal widening.]] | ||
*[[CXR]]/CT | |||
**Widened mediastinum representing hemorrhagic mediastinitis | |||
**Infiltrate, pleural effusion | |||
**Hyperdense mediastinal lymphadenopathy | |||
== | ==Management== | ||
'''Contact CDC Emergency Hotline 1-707-488-7100 for all suspected bioterrorism cases''' | '''Contact CDC Emergency Hotline 1-707-488-7100 for all suspected bioterrorism cases''' | ||
| Line 70: | Line 90: | ||
[[Category:ID]] | [[Category:ID]] | ||
Latest revision as of 18:20, 21 September 2022
Background
- Gram positive rod, Bacillus anthracis, which is capable of surviving inhospitable conditions through the formation of endospores
- Incubation period is 10 days with no ability for human to human transmission and therefore, no need for respiratory isolation
- Though human to human transmission does not occur, potential harbors of spores (patient clothes) need to be isolated and decontaminated with 10% bleach[1]
- In general there is cutaneous, inhalational, and gastrointesinal anthrax.
Clinical Features
Inhalational (5%)
- Biphasic course
Prodrome Period
- Early prodromal period often appears as an flu-like illness
- Fever, dry cough, myalgia, malaise
- Transient clinical improvement followed by rapid decline
Acute phase
- Severe respiratory distress with symptoms consisting of[2]:
- Hypoxia, tachypnea, cyanosis
- Severe dyspnea, chest pain
- Shock
- Mediastinitis
Cutaneous (95%)
- The disease will start as an area of erythema and edema and progress to a vesicle which ruptures forming a central black eschar which eventually falls off
- Total course of lesion evolution occurs over 1 week
- Small minority of untreated patients develop rapidly fatal bacteremia [3]
Gastrointestinal
- Over the course of 7 days, nonspecific abdominal pain, nausea and vomiting with progress to severe abdominal pain, bloody emesis and diarrhea (usually bloody)[4]
- May present as oropharyngeal ulcers with dysphagia
Differential Diagnosis
Cutaneous (painless)
- Ecthyma gangrenosum
- Rat-bite fever (Streptobacillus monilifomis and Spirillum minus)
- Ulceroglandular tularemia
- Plague
- Glanders (Pseudomonas peudomallei)
- Rickettsial pox (Rickettsia akari)
- Orf (parapox virus)
- Staph lymphadenitis
- TB
- Leprosy
- Buruli ulcer (Mycobact ulcerans)
Inhalational
- Acute bacterial mediastinitis
- Mycoplasma
- Legionnaire's
- Psittacosis
- Tularemia
- Q fever (Coxiella burnetti)
- Viral pneumonia
- Histoplasmosis
- Coccidiomycosis
- Ruptured Aortic Dissection
- SVC syndrome
- Silicosis
- Sarcoidosis
Lower Respiratory Zoonotic Infections
- Psittacosis
- Anthrax (Bacillus anthracis)
- Brucellosis (Brucella species)
- Q fever (C. burnetti)
- Pasteurellosis (Pasteurella multocida)
- Melioidosis (Burkholderia pseudomallei)
- Rocky Mountain Spotted Fever (R. rickettsii)
- Pulmonic Plague (Yersinia pestis)
- Influenza A
- Hantavirus
Bioterrorism Agents[5]
Category A
Category B
- Ricin
- Brucellosis
- Epsilon toxin
- Psittacosis
- Q Fever
- Staph enterotoxin B
- Typhus
- Glanders
- Melioidosis
- Food safety threats
- Water safety threats
- Viral encephalitis
Category C
- Influenza
- Yellow fever
- Tickborne hemorrhagic fever
- Tickborne encephalitis
Evaluation
CXR of inhalational anthrax showing mediastinal widening.
- CXR/CT
- Widened mediastinum representing hemorrhagic mediastinitis
- Infiltrate, pleural effusion
- Hyperdense mediastinal lymphadenopathy
Management
Contact CDC Emergency Hotline 1-707-488-7100 for all suspected bioterrorism cases
Postexposure Prophylaxis
Patient should be vaccinated at day #0, #14, #28
- Ciprofloxacin 500mg PO q12hrs daily x 60 days OR
- Doxycycline 100mg PO q12hrs x 60 days
Cutaneous Anthrax (not systemically ill)
- Ciprofloxacin 500mg PO q12hrs x 60 days
- Doxycycline 100mg PO q12hrs x 60 days
Inhalation or Cutaneous with systemic illness
- Ciprofloxacin 400mg IV q12hrs x 60 days (1st line) OR
- Doxycycline 100mg IV q12hrs x 60days (only if allergic to ciprofloxacin) PLUS
- Clindamycin 900mg IV q8hrs
Pediatric Postexpsoure Prophylaxis
- Ciprofloxacin 15mg/kg PO q12hrs x 60 days
- Doxycycline 2.2mg/kg PO q12hrs x 60 days
Pediatric Cutaneous Anthrax (not ill)
- Same as post exposure dosing and duration
Pediatric Inhalational or Cutaneous (systemically ill
- Ciprofloxacin 15mg/kg IV q12hrs (1st line) OR
- Doxycycline 2.2mg/kg IV q12hrs (only if allergic to cipro) PLUS
- Clindamycin 7.5mg/kg q6hrs daily
Disposition
- Admit
See Also
References
- ↑ Heninger SJ et al. Decontamination of Bacillus anthracis Spores: Evaluation of Various Disinfectants. Appl Biosaf. 2009 Jan 1; 14(1): 7–10.
- ↑ Medscape: Anthrax
- ↑ Gordon, David. "Zoonotic Infections." Tintinalli's Emergency Medicine Manual, 8e Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH.
- ↑ CDC. Gastrointestinal anthrax after an animal-hide drumming event - New Hampshire and Massachusetts, 2009. MMWR Morb Mortal Wkly Rep. 2010 Jul 23;59(28):872-7. http://www.ncbi.nlm.nih.gov/pubmed/20651643
- ↑ https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx Accessed 02/26/16