Anthrax

Anthrax 

Definition

Anthrax is an infection caused by the bacterium Bacillus anthracis that primarily affects livestock but that can occasionally spread to humans, affecting either the skin, intestines, or lungs. In humans, the infection can often be treated, but it is almost always fatal in animals.

Description

Anthrax is most often found in the agricultural areas of South and Central America, southern and eastern Europe, Asia, Africa, the Caribbean, and the Middle East. In the United States, anthrax is rarely reported; however, cases of animal infection with anthrax are most often reported in Texas, Louisiana, Mississippi, Oklahoma, and South Dakota. The bacterium and its associated disease get their name from the Greek word meaning "coal" because of the characteristic coal-black sore that is the hallmark of the most common form of the disease.

During the 1800s, in England and Germany, anthrax was known either as "wool-sorter's" or "ragpicker's" disease because workers contracted the disease from bacterial spores present on hides and in wool or fabric fibers. Spores are the small, thick-walled dormant stage of some bacteria that enable them to survive for long periods of time under adverse conditions. The first anthrax vaccine was perfected in 1881 by Louis Pasteur.

The largest outbreak ever recorded in the United States occurred in 1957 when nine employees of a goat hair processing plant became ill after handling a contaminated shipment from Pakistan. Four of the five patients with the pulmonary form of the disease died. Other cases appeared in the 1970s when contaminated goatskin drumheads from Haiti were brought into the U.S. as souvenirs.

Today, anthrax is rare, even among cattle, largely because of widespread animal vaccination. However, some serious epidemics continue to occur among animal herds and in human settlements in developing countries due to ineffective control programs. In humans, the disease is almost always an occupational hazard, contracted by those who handle animal hides (farmers, butchers, and veterinarians) or sort wool. There are no reports of the disease spreading from one person to another.

Anthrax as a weapon

There has been a great deal of recent concern that the bacteria that cause anthrax may be used as a type of biological warfare, since it is possible to become infected simply by inhaling the spores, and inhaled anthrax is the most serious form of the disease. The bacteria can be grown in laboratories, and with a great deal of expertise and special equipment, the bacteria can be altered to be usable as a weapon.

The largest-ever documented outbreak of human anthrax contracted through spore inhalation occurred in Russia in 1979, when anthrax spores were accidentally released from a military laboratory, causing a regional epidemic that killed 69 of its 77 victims. In the United States in 2001, terrorists converted anthrax spores into a powder that could be inhaled and mailed it to intended targets, including news agencies and prominent individuals in the federal government. Because the United States government considers anthrax to be of potential risk to soldiers, the Department of Defense has begun systematic vaccination of all military personnel against anthrax. For civilians in the United States, the government has instituted a program called the National Pharmaceutical Stockpile program in which antibiotics and other medical materials to treat two million people are located so that they could be received anywhere in the country within twelve hours following a disaster or terrorist attack.

Causes and symptoms

The naturally occurring bacterium Bacillus anthracis produces spores that can remain dormant for years in soil and on animal products, such as hides, wool, hair, or bones. The disease is often fatal to cattle, sheep, and goats, and their hides, wool, and bones are often heavily contaminated.

The bacteria are found in many types of soil, all over the world, and usually do not pose a problem for humans because the spores stay in the ground. In order to infect a human, the spores have to be released from the soil and must enter the body. They can enter the body through a cut in the skin, through consuming contaminated meat, or through inhaling the spores. Once the spores are in the body, and if antibiotics are not administered, the spores become bacteria that multiply and release a toxin that affects the immune system. In the inhaled form of the infection, the immune system can become overwhelmed and the body can go into shock.

Symptoms vary depending on how the disease was contracted, but the symptoms usually appear within one week of exposure.

Key terms

Antibody — A specific protein produced by the immune system in response to a specific foreign protein or particle called an antigen.

Antitoxin — An antibody that neutralizes a toxin.

Bronchitis — Inflammation of the mucous membrane of the bronchial tubes of the lung that can make it difficult to breathe.

Cutaneous — Pertaining to the skin

Meningitis — Inflammation of the membranes covering the brain and spinal cord called the meninges.

Pulmonary — Having to do with the lungs or respiratory system.

Spore — A dormant form assumed by some bacteria, such as anthrax, that enable the bacterium to survive high temperatures, dryness, and lack of nourishment for long periods of time. Under proper conditions, the spore may revert to the actively multiplying form of the bacteria.

Cutaneous anthrax

In humans, anthrax usually occurs when the spores enter a cut or abrasion, causing a skin (cutaneous) infection at the site. Cutaneous anthrax, as this infection is called, is the mildest and most common form of the disease. At first, the bacteria cause an itchy, raised area like an insect bite. Within one to two days, inflammation occurs around the raised area, and a blister forms around an area of dying tissue that becomes black in the center. Other symptoms may include shivering and chills. In most cases, the bacteria remain within the sore. If, however, they spread to the nearest lymph node (or, in rare cases, escape into the bloodstream), the bacteria can cause a form of blood poisoning that rapidly proves fatal.

Inhalation anthrax

Inhaling the bacterial spores can lead to a rare, often-fatal form of anthrax known as pulmonary or inhalation anthrax that attacks the lungs and sometimes spreads to the brain. Inhalation anthrax begins with flulike symptoms, namely fever, fatigue, headache, muscle aches, and shortness of breath. As early as one day after these initial symptoms appear, and as long as two weeks later, the symptoms suddenly worsen and progress to bronchitis. The patient experiences difficulty breathing, and finally, the patient enters a state of shock. This rare form of anthrax is often fatal, even if treated within one or two days after the symptoms appear.

Intestinal anthrax

Intestinal anthrax is a rare, often-fatal form of the disease, caused by eating meat from an animal that died of anthrax. Intestinal anthrax causes stomach and intestinal inflammation and sores or lesions (ulcers), much like the sores that appear on the skin in the cutaneous form of anthrax. The first signs of the disease are nausea and vomiting, loss of appetite, and fever, followed by abdominal pain, vomiting of blood, and severe bloody diarrhea.

Diagnosis

Anthrax is diagnosed by detecting B. anthracis in samples taken from blood, spinal fluid, skin lesions, or respiratory secretions. The bacteria may be positively identified using biochemical methods or using a technique whereby, if present in the sample, the anthrax bacterium is made to fluoresce. Blood samples will also indicate elevated antibody levels or increased amounts of a protein produced directly in response to infection with the anthrax bacterium. Polymerase chain reaction (PCR) tests amplify trace amounts of DNA to show that the anthrax bacteria are present. Additional DNA-based tests are also currently being perfected.

Treatment

In the early stages, anthrax is curable by administering high doses of antibiotics, but in the advanced stages, it can be fatal. If anthrax is suspected, health care professionals may begin to treat the patient with antibiotics even before the diagnosis is confirmed because early intervention is essential. The antibiotics used include penicillin, doxycycline, and ciprofloxacin. Because inhaled spores can remain in the body for a long time, antibiotic treatment for inhalation anthrax should continue for 60 days. In the case of cutaneous anthrax, the infection may be cured following a single dose of antibiotic, but it is important to continue treatment so as to avoid potential serious complications, such as inflammation of the membranes covering the brain and spinal cord (meningitis). In the setting of potential bioterrorism, cutaneous anthrax should be treated with a 60-day dose of antibiotics.

Research is ongoing to develop new antibiotics and antitoxins that would work against the anthrax bacteria and the toxins they produce. One Harvard professor, Dr. R. John Collier, and his team have been testing two possible antitoxins on rats. A Stanford microbiologist and a Penn State chemist have also been testing their new antibiotic against the bacteria that cause brucellosis and tularemia, as well as the bacteria that cause anthrax. All of these drugs are still in early investigational stages, however, and it is still unknown how these drugs would affect humans.

Prognosis

Untreated anthrax is often fatal, but death is far less likely with appropriate care. Ten to twenty percent of patients will die from anthrax of the skin (cutaneous anthrax) if it is not properly treated. All patients with inhalation (pulmonary) anthrax will die if untreated. Intestinal anthrax is fatal 25-75% of the time.

Prevention

Anthrax is relatively rare in the United States because of widespread animal vaccination and practices used to disinfect hides or other animal products. Anyone visiting a country where anthrax is common or where herd animals are not often vaccinated should avoid contact with livestock or animal products and avoid eating meat that has not been properly prepared and cooked.

Other means of preventing the spread of infection include carefully handling dead animals suspected of having the disease, burning (instead of burying) contaminated carcasses, and providing good ventilation when processing hides, fur, wool, or hair.

In the event that exposure to anthrax spores is known, such as in the aftermath of a terrorist attack, a course of antibiotics can prevent the disease from occurring.

In the case of contaminated mail, as was the case in the 2001 attacks, the U.S. postal service recommends certain precautions. These precautions include inspecting mail from an unknown sender for excessive tape, powder, uneven weight or lumpy spots, restrictive endorsements such as "Personal," or "Confidential," a postmark different from the sender's address, or a sender's address that seems false or that cannot be verified. Handwashing is also recommended after handling mail. In order to decontaminate batches of mail before being opened, machines that use bacteria-killing radiation could be used to sterilize the mail. These machines are similar to systems already in place on assembly lines for sterile products, such as bandages and medical devices, but this technique would not be practical for large quantities of mail. In addition, the radiation could damage some of the mail's contents, such as undeveloped photographic film. Microwave radiation or the heat from a clothes iron is not powerful enough to kill the anthrax bacteria.

For those in high-risk professions, an anthrax vaccine is available that is 93% effective in protecting against infection. To provide this immunity, an individual should be given an initial course of three injections, given two weeks apart, followed by booster injections at six, 12, and 18 months and an annual immunization thereafter.

Approximately 30% of those who have been vaccinated against anthrax may notice mild local reactions, such as tenderness at the injection site. Infrequently, there may be a severe local reaction with extensive swelling of the forearm, and a few vaccine recipients may have a more general flu-like reaction to the shot, including muscle and joint aches, headache, and fatigue. Reactions requiring hospitalization are very rare. However, this vaccine is only available to people who are at high risk, including veterinary and laboratory workers, livestock handlers, and military personnel. The vaccine is not recommended for people who have previously recovered from an anthrax infection or for pregnant women. Whether this vaccine would protect against anthrax used as a biological weapon is, as yet, unclear.

Resources

Organizations

Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. http://www.cdc.gov.

National Institute of Allergies and Infectious Diseases, Division of Microbiology and Infectious Diseases. Building 31, Room. 7A-50, 31 Center Drive MSC 2520, Bethesda, MD 20892. http://www.niaid.nih.gov.

World Health Organization, Division of Emerging and Other Communicable Diseases Surveillance and Control. Avenue Appia 20, 1211 Geneva 27, Switzerland. (+00 41 22) 791 21 11. http://www.who.int.

Other

"Anthrax." New York State Department of Health Communicable Disease Fact Sheet. http://www.health.state.ny.us/nysdoh/consumer/anthrax.htm.

"Bacillus anthracis (Anthrax)." 〈http://web.bu.edu/COHIS/infxns/bacteria/anthrax.htm〉.

Begley, Sharon and Karen Springen. "Anthrax: What You Need to Know: Exposure doesn't guarantee disease, and the illness is treatable." Newsweek October 29, 2001: 40.

Centers for Disease Control. http://www.cdc.gov.

Kolata, Gina. "Antibiotics and Antitoxins." New York Times October 23, 2001: Section D, page 4, second column.

Park, Alice. "Anthrax: A Medical Guide." Time 158, no. 19 (October 29, 2001): 44.

Shapiro, Bruce. "Anthrax Anxiety." The Nation 273, no. 4 (November 5, 2001): 4.

Wade, Nicholas. "How a Patient Assassin Does Its Deadly Work." New York Times October 23, 2001: Section D, page 1.

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anthrax /an·thrax/ (an´thraks) an often fatal, infectious disease of ruminants due to ingestion of spores of Bacillus anthracis in soil; acquired by humans through contact with contaminated wool or other animal products or by inhalation of airborne spores.

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cutaneous anthrax  that due to inoculation of Bacillus anthracis into superficial wounds or abrasions of the skin, producing a black crusted pustule on a broad zone of edema.

gastrointestinal anthrax  intestinal a.

inhalational anthrax  a highly fatal form due to inhalation of dust containing anthrax spores, which are transported by alveolar pneumocytes to regional lymph nodes, where they germinate; it is primarily an occupational disease seen in those who handle and sort wools and fleeces.

intestinal anthrax  anthrax involving the gastrointestinal tract, caused by ingestion of poorly cooked meat contaminated by Bacillus anthracis spores; bowel obstruction, hemorrhage, and necrosis may result.

pulmonary anthrax  inhalational a.

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an·thrax (nthrks)

n.

1. An infectious, usually fatal disease of warm-blooded animals that is characterized by ulcerative skin lesions, can be transmitted to humans, and is caused by the bacterium Bacillus anthracis. Also called carbuncle.

2. pl. an·thra·ces (-thr-sz) A lesion caused by anthrax.

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an·thrac·ic (n-thrsk) adj.

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anthrax (an´thraks),

n an infectious disease in herbivorous animals caused by a spore-forming
Bacillus organism. Primary lesions in human beings may be on the lips or cheeks.

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anthrax

a peracute disease of all animal species, caused by Bacillus anthracis, and characterized by septicemia and sudden death. The causative bacteria form long-living spores which maintain the disease on a farm for many years. Significant necropsy findings include exudation of dark, tarry blood from the body orifices, failure of the blood to clot, absence of rigor mortis and splenomegaly. A dangerous zoonosis. Easily controlled by vaccination of livestock.

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alimentary anthrax

infection resulting from the ingestion of animals dead of anthrax. Largely a human manifestation in developing countries.

anthrax belt

regions where anthrax is enzootic, where soil and climate favor persistence of the organism in soil and where routine efforts to control the disease are not sufficient. Outbreaks commonly follow climatic extremes of flood or drought.

cutaneous anthrax

anthrax due to lodgment of the causative organisms in wounds or abrasions of the skin, producing a black crusted pustule on a broad zone of edema. A common form of the disease in humans.

pulmonary anthrax

infection of the respiratory tract resulting from inhalation of dust or animal hair containing spores of Bacillus anthracis; an occupational disease of humans usually affecting those who handle and sort wools and fleeces (woolsorters' disease).

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anthrax Greek, anthrax, a burning coal, charbon, milzbrand Infectious disease An often fatal bacterial infection which occurs when Bacillus anthracis endospores, primarily of grazing herbivore–cattle, sheep, horses, mules–origin enter via skin abrasions, inhalation, or orally Pathogenesis Anthrax endospores germinate within macrophages, become vegetative bacteria, multiply within the lymphatics, enter the bloodstream and cause massive septicemia Clinical URI-like symptoms, followed by high fever, vomiting, joint pain, SOB, internal and external hemorrhage, hypotension, meningitis, pulmonary edema, shock sudden death; intestinal anthrax is caused by ingestion of contaminated meat; cutaneous anthrax is rare Diagnosis ELISA for capsule antigens–95+% senstivity, for protective antigen–72% sensitivity; detection of exotoxins in blood is unreliable Prevention Prophylaxis–6 wks with doxycycline or ciprofloxacin; vaccination, with anthrax vaccine absorbed; decontamination with aerosolized formalin Management Penicillin, doxycycline; if allergic to penicillin, chloramaphenicol, erythromycin, tetracycline, ciprofloxacin See Bacillus anthracis, Cutaneous anthrax, Industrial anthrax, Inhalation anthrax

Anthrax, clinical forms

Pulmonary

Almost universally fatal–due to inhalation of anthrax spores which germinate and produce toxins resulting in pleural effusions, hemorrhage, cyanosis, SOB, stridor, shock, death

Inhalation

Anthrax pneumonia, inhalational anthrax, pulmonary anthrax An almost universally fatal form due to inhalation of 1 to 2 µm pathogenic endospores which are deposited in alveoli, engulfed by macrophages and germinate en route to the mediastinal and peribronchial lymph nodes, produce toxins Clinical Mediastinal widening, pleural effusions, fever, nonproductive cough, myalgia, malaise, hemorrhage, cyanosis, SOB, stridor, shock, death, often accompanied by mesenteric lymphadenitis, diffuse abdominal pain, fever

Cutaneous

Once common among handlers of infected animals, eg farmers, woolsorters, tanners, brushmakers and carpetmakers in an era when brushes were from animals Clinical Carbuncle–a cluster of boils, that later ulcerates, resulting in a hard black center surrounded by bright red inflammation; rare cases which become systemic are almost 100% fatal

Gastrointestinal

After ingesting contaminated meat–2 to 5 days; once ingested spores germinate, causing ulceration, hemorrhagic and necrotizing gastroenteritis Clinical Fever, diffuse abdominal pain with rebound tenderness, melanic stools, vomit, fluid and electrolyte imbalances, shock; death is due to intestinal perforation or anthrax toxemia

Oropharyngeal

Uncommon, follows ingestion of contaminated meat Clinical Cervical edema, lymphadenopathy–causing dysphagia, respiratory difficulty

Anthrax meningitis

A rare, usually fatal complication of GI or inhalation anthrax with death occurring 1 to 6 days after onset of illness Clinical Meningeal symptoms, nuchal rigidity, fever, fatigue, myalgia, headache, N&V, agitation, seizures, delirium, followed by neurologic degeneration and death

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