Case of the Week: Anthrax

I admitted the patient above to the hospital; not because I actually had a clue about what was wrong with him, but because I knew what was happening to him was NOT right.  He told me the swelling in his neck had happened over a few days and I was worried if it continued to swell he would obstruct his airway.  I thought it was strange that so much swelling happened over a few days and could not place the rash that he had overlying the swelling.  I asked Dr. Hewitt to take a look at the patient in the ward because I did not know what to do with him and he remark without blinking, “Oh, this is just cutaneous anthrax.”

 

If you remember, anthrax was launched into the US news in 2001 with a death from inhaled anthrax from a deliberately contaminated letter.  Over a few months, there were 13 cases of cutaneous anthrax and 11 cases of inhalation anthrax all associated with exposure to contaminated mail.  This spread fear of bioterrorism across the nation (including into the head of a young curly haired family member, who will remain unnamed, who saved a letter in a plastic bag for weeks that had some “powder” she insisted fell out when she opened it, thinking the Frontenac police should investigate it for anthrax).

Well, here in Ghana we have naturally occurring anthrax which is a disease of sheep, cattle, horses, goats, and swine.  Bacillus anthracis is a gram positive spore forming aerobic rod.  The spores are the infectious form of the organism.  It is spread to humans through contact with contaminated animals, animal products, hides, or soil by inoculation of broken skin or by inhalation of aerosolized spores, rarely by ingestion of the spores.  The result is cutaneous, inhalational, or gastrointestinal anthrax.

Cutaneous anthrax occurs within two weeks after exposure to spores.  The lesion initially looks like an erythematous papule that then vesiculates and ulcerates.  It undergoes necrosis and eventually turns to a purple / black eschar.  This lesion is typically painless.  The most impressive aspect is the surrounding area of edema.  Patients may have fever, malaise, headache, nausea, and vomiting.  Infection is usually self-limited in most cases, but hematogenous spread with sepsis or meningitis may occur.  The infection can be treated with penicillin, however, in many places resistance to PCN has formed so it is currently recommended to treat with ciprofloxacin for two weeks.  Cutaneous anthrax is the least worrisome of the potential forms of infection and recovery is excellent, however with inhalational or gastrointestinal anthrax there is up to an 85% mortality rate.

In questioning this patient further, he had killed a sheep a week before his symptoms started.  He was started on antibiotics and did very well.  I will defiantly never forget what this infection looks like and next time I see it I am planning on nonchalantly saying, “Oh, this is just cutaneous anthrax.”