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Report of 2 Patients

Luciana Borio, MD; Dennis Frank, MD; Venkat Mani, MD; Carlos Chiriboga, MD; Michael Pollanen, MD,PhD; Mary Ripple, MD; Syed Ali, MD; Constance DiAngelo, MD,MS; Jacqueline Lee, MD; Jonathan Arden, MD; Jack Titus, MD; David Fowler, MD; Tara O'Toole, MD,MPH; Henry Masur, MD; John Bartlett, MD; Thomas Inglesby, MD

JAMA. 2001;286:2554-2559.

On October 9, 2001, a letter containing anthrax spores was mailed from New Jersey to Washington, DC. The letter was processed at a major postal facility in Washington, DC, and opened in the Senate's Hart Office Building on October 15. Between October 19 and October 26, there were 5 cases of inhalational anthrax among postal workers who were employed at that major facility or who handled bulk mail originating from that facility. The cases of 2 postal workers who died of inhalational anthrax are reported here. Both patients had nonspecific prodromal illnesses. One patient developed predominantly gastrointestinal symptoms, including nausea, vomiting, and abdominal pain. The other patient had a "flulike" illness associated with myalgias and malaise. Both patients ultimately developed dyspnea, retrosternal chest pressure, and respiratory failure requiring mechanical ventilation. Leukocytosis and hemoconcentration were noted in both cases prior to death. Both patients had evidence of mediastinitis and extensive pulmonary infiltrates late in their course of illness. The durations of illness were 7 days and 5 days from onset of symptoms to death; both patients died within 24 hours of hospitalization. Without a clinician's high index of suspicion, the diagnosis of inhalational anthrax is difficult during nonspecific prodromal illness. Clinicians have an urgent need for prompt communication of vital epidemiologic information that could focus their diagnostic evaluation. Rapid diagnostic assays to distinguish more common infectious processes from agents of bioterrorism also could improve management strategies.

Author Affiliations: Johns Hopkins Center for Civilian Biodefense Studies of Johns Hopkins Schools of Medicine and Public Health (Drs Borio, O'Toole, Bartlett, and Inglesby) and Office of the Chief Medical Examiner for the State of Maryland (Drs Ripple, Titus, and Fowler), Baltimore; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Md (Drs Borio and Masur); Greater Southeast Community Hospital (Drs Frank and Ali) and Office of the Chief Medical Examiner for the District of Columbia (Drs Pollanen, DiAngelo, Lee, and Arden), Washington, DC; and Southern Maryland Hospital Center, Clinton (Drs Mani and Chiriboga).

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