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To the Editor: Dr Borio and colleagues¹ described 2 patients who died of inhalation anthrax. Some factors in the first patient's case, however, raise concern that there was an initial gastrointestinal anthrax infection in addition to the inhalational illness, which became apparent later. The patient's prodrome consisted of nausea, vomiting, and abdominal pain, diagnosed by the patient himself as food poisoning. He did not complain of chest or respiratory symptoms on his first visit, and the symptom constellation prompted the initial treating physician to diagnose gastroenteritis. The postmortem examination confirmed a focal infection of the ileum, although mesenteric nodes were apparently unaffected.

Given the sequence of the patient's symptoms, it seems reasonable to suspect that this gastrointestinal infection developed with the inhalational illness and was not a subsequent metastatic event. If gastrointestinal anthrax as well as inhalational anthrax can be acquired through exposure to contaminated materials and work areas, it is possible that physicians may see isolated gastrointestinal infection and must therefore be alert for a wider range of presenting signs and symptoms to identify anthrax infection at an early stage.

Robert S. Porter, MD
Albert Einstein Medical Center
Philadelphia, Pa

1. Borio L, Frank D, Mani V, et al. Death due to bioterrorism-related inhalational anthrax: report of 2 patients. JAMA. 2001;286:2554-2559. FREE FULL TEXT

To the Editor: Dr Borio and colleagues¹ discussed the role of clinicians in their description of 2 patients who died of bioterrorism-related inhalational anthrax. However, they did not mention the role of the medical examiner in these cases, despite the fact that both patients underwent autopsies by medical examiners. Medicolegal death investigators (ie, medical examiners and coroners) in each state are authorized by statutes to investigate deaths that are sudden, violent, suspicious, or unexplained.² These cases include deaths attributable to homicide and inapparent causes such as some infectious diseases and toxic exposures.³ As Borio et al concluded, deaths from known terrorist events are homicides; therefore, they fall under the jurisdiction of medical examiners and coroners. Because medical examiners and coroners are also an important arm of surveillance for unrecognized terrorist attacks,³ clinicians must report suspicious deaths and confirmed deaths caused by terrorism to the proper medicolegal authorities for investigation.

The autopsies described by Borio et al confirmed anthrax as the cause of death and inhalation as the route of infection. Although underused, autopsies have been valuable in diagnosing undetected infections, assessing antemortem therapy, and understanding the pathogenesis of new or unusual infections.⁴ In addition, medicolegal autopsies develop evidence that can be used in legal proceedings.³

Borio et al advocate rapid communication of epidemiologic data to front-line medical care providers (especially emergency physicians and primary care clinicians) to facilitate appropriate diagnostic procedures and therapy. Medical examiners are also front-line medical providers and diagnosticians who should be integrated into the enhanced communications from public health agencies. To be successful, a coordinated response to bioterrorism requires participation from all of the components.

Kurt B. Nolte, MD
Office of the Medical Investigator
University of New Mexico School of Medicine
Albuquerque

1. Borio L, Frank D, Mani V, et al. Death due to bioterrorism-related inhalational anthrax: report of 2 patients. JAMA. 2001;286:2554-2559. FREE FULL TEXT 2. Combs DL, Parrish RG, Ing R. Death Investigation in the United States and Canada, 1995. Atlanta, Ga: Centers for Disease Control and Prevention; 1995. 3. Nolte KB, Yoon SS, Pertowski C. Medical examiners, coroners, and bioterrorism. Emerg Infect Dis. 2000;6:559-560. PUBMED 4. Schwartz DA, Bryan RT, Hughes JM. Pathology and emerging infections—quo vadimus? Am J Pathol. 1995;147:1525-1533. ABSTRACT

In Reply: In response to Dr Porter, the first patient indeed had prominent gastrointestinal manifestations. In the absence of a postmortem examination, one might have assumed that gastrointestinal anthrax was either the primary or a concomitant mechanism of illness and cause of death. However, postmortem examination did not reveal evidence of primary gastrointestinal anthrax, such as mucosal ulceration of the small or large bowel. The observed hemorrhage, necrotizing infection, and inflammation proceeded from the serosa to the lamina propria of the submucosa, sparing the mucosa. In addition, the mesenteric lymph nodes were unremarkable.

Twenty of 33 patients who died of inhalational anthrax in Sverdlovsk in 1979 after exposure to anthrax spores accidentally released from a bioweapons facility had gastrointestinal involvement with Bacillus anthracis on postmortem examination.¹ Enteric findings in that series of patients included B anthracis in the walls of the intestines, submucosal hematomas, diffuse enteric hemorrhage, vasculitis, cellulitis, and edema. After the inhalation of anthrax spores, a hilar lymphadenitis and hemorrhagic mediastinitis develop. Later, bacteremia or lymphangitis may spread to virtually all organs, including the intestines.

We agree with Dr Nolte that medical examiners are an important component of public health surveillance. We hope that these recent unfortunate events remind clinicians that suspicious or unexplained illnesses or deaths need to be immediately reported to the appropriate public health authority and to the medical examiner in their jurisdiction, as happened in these cases. The autopsy examination in a case of homicide can be essential for defining the mechanisms of disease and identifying the cause of death when the etiologic agent is unknown.

Luciana L. Borio, MD
Johns Hopkins Center for Civilian Biodefense Strategies
Johns Hopkins University Schools of Medicine and Public Health
Baltimore, Md
Critical Care Medicine Department
Clinical Center
National Institutes of Health
Bethesda, Md

1. Grinberg LM, Abramova FA, Yampolskaya OV, Walker DH, Smith JH. Quantitative pathology of inhalational anthrax, I: quantitative microscopic findings. Mod Pathol. 2001;14:482-495. FULL TEXT | ISI

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2002;287:984-985.

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Death Due to Bioterrorism-Related Inhalational Anthrax: Report of 2 Patients
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