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Recognition and Treatment of Anthrax
To the Editor: The Consensus Statement on anthrax as a biological weapon by Dr Inglesby and colleagues1 included much useful information, but the treatment section mentioned only antibiotics. In contrast, a clinical report2 of 1 of the few patients to survive intestinal anthrax contains important information about other aspects of effective management. This patient, who had purulent ascitic fluid, appeared to present with an acute abdomen, and had unnecessary surgery as a result. A gram-positive rod in the blood cultures was initially called a contaminant by the laboratory. The patient's course was complicated by pneumonitis, gastrointestinal hemorrhage with melena (probably from the site of primary intestinal infection), and focal cerebritis or meningitis. Prolonged antibiotic therapy was necessary to treat his disseminated infection, but he probably would not have survived without meticulous attention to water and electrolyte balance, prompt replacement of blood losses, and achievement of hemostasis.
David R. Nalin, MD
Merck Vaccine Division
West Point, Pa
1. Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon: medical and public health management. JAMA. 1999;281:1735-1745.
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2. Nalin D, Sultana B, Sahunja R, et al. Survival of a patient with intestinal anthrax. Am J Med. 1977;62:130-132.
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In Reply: Dr Nalin highlights important diagnosis and treatment issues for patients with gastrointestinal anthrax. Nalin and colleagues1 described the clinical presentation, treatment and hospital course of a 17-year-old Bangalee student who presented with what appeared to be an acute abdomen. During laparotomy, he was found to have intact viscera with mesenteric lymphadenopathy and semipurulent ascitic fluid. Microbiologic studies subsequently revealed Bacillus anthracis as the etiologic agent.
This case report underscores a number of important points delineated in our article. Bacillus anthracis may erroneously be dismissed as a contaminant when discovered in blood cultures. As we mentioned in our article, the management of a patient with anthrax-related sepsis may be optimized by "vigilant correction of electrolyte disturbances and acid-base imbalance, glucose infusion, and early mechanical ventilation and vasopressor administration." A prolonged antibiotic course is indicated for treatment of inhalational or gastrointestinal anthrax.
While it is difficult to draw conclusions regarding the efficacy of treatment interventions from a single case report, the interventions recommended by Nalin are consistent with those of our consensus statement, as well as those of other investigators.2-5
Thomas V. Inglesby, MD;
Donald A. Henderson, MD, MPH
Johns Hopkins School of Public Health
Baltimore, Md
1. Nalin DR, Sultana B, Sahunja R, et al. Survival of a patient with intestinal anthrax. Am J Med. 1977;62:130-132.
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2. Dulz W, Saidi F, Kouhout E. Gastric anthrax with massive ascites. Gut. 1970;11:352-354.
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3. Kunanusont C, Limpakarnjanarat K, Foy HM. Outbreak of anthrax in Thailand. Ann Trop Med Parasitol. 1989;84:507-512.
4. Walker JS, Lincoln RE, Klein F. Pathophysiological and biochemical changes in anthrax. Fed Proc. 1967;26:1539-1544.
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5. Tekin A, Bulut N, Unal T. Acute abdomen due to anthrax. Br J Surg. 1997;84:813.
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Edited by Margaret A. Winker, MD, Deputy Editor, and Phil B. Fontanarosa, MD, Interim Coeditor.
JAMA. 1999;282:1624-1625.
RELATED ARTICLE
Anthrax as a Biological Weapon: Medical and Public Health Management
Thomas V. Inglesby, Donald A. Henderson, John G. Bartlett, Michael S. Ascher, Edward Eitzen, Arthur M. Friedlander, Jerome Hauer, Joseph McDade, Michael T. Osterholm, Tara O'Toole, Gerald Parker, Trish M. Perl, Philip K. Russell, Kevin Tonat, and for the Working Group on Civilian Biodefense
JAMA. 1999;281(18):1735-1745.
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