Pediatric emergency medicine trisk 4546 4546
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anthrax-contaminated mail. The attack resulted in enormous public anxiety, as
well as major demands for medical care and public health resources. Antibiotic
prophylaxis was prescribed for more than 30,000 persons, and decontamination of
the Hart Senate Office Building alone took months and was extremely costly.
Many bioterrorism defense experts, however, fear an even more widespread
aerosol release that could potentially sicken hundreds of thousands.
Inhalational anthrax is the disease form that poses the greatest threat.
Following the accidental release of anthrax spores from a Soviet military facility
at Sverdlovsk in 1979, 66 of 77 known victims of inhalational anthrax died. In the
recent U.S. attack, all 5 deaths occurred among the 11 patients with this form of
disease.
Pathophysiology/Common Manifestations. Inhalational anthrax results from
spore uptake in the alveoli by pulmonary macrophages, followed by bacterial
germination and toxin production in the mediastinal lymph nodes, leading to
hemorrhagic lymphadenitis, mediastinitis, and sepsis. Symptoms typically begin
1 to 5 days after exposure, although incubation periods up to several weeks in
length have been reported. The disease begins as a nonspecific influenza-like
illness, characterized by fever, headache, myalgia, and cough. The relative lack of
eye, nose, and throat findings such as red, watery eyes, rhinorrhea, or pharyngitis
helps to distinguish this phase from common viral infections. A brief intervening
period of improvement sometimes follows, but rapid deterioration then ensues
with high fever, dyspnea, cyanosis, and shock marking this second phase.
Hemorrhagic meningitis occurs in up to 50% of cases. Chest radiographs or
computed tomography scans may reveal a widened mediastinum or prominent
mediastinal lymphadenopathy; infiltrates and pleural effusions may also be seen.
Gram stains of peripheral blood smears at this stage may demonstrate grampositive rods. Prompt treatment is imperative as, historically, death occurred in as
many as 95% of inhalational anthrax cases if such treatment began more than 48
hours after symptom onset. Even with modern intensive care, in the 2001 anthrax
attack, all four patients with inhalational anthrax who exhibited signs of fulminant
disease prior to antibiotic administration died. Thus, in the context of a known
bioterrorism incident, a potential dilemma facing emergency care providers
involves deciding which patients presenting with nonspecific flu-like, febrile
illness are candidates for empiric antibiotic therapy.
Cutaneous anthrax occurs when organisms gain entry into skin, usually
through abrasions or cuts. It is characterized by the appearance of a papule at the
inoculum site, which then progresses over days to a vesicle, then to an ulcer, and
