24 May 2005

24 May=20 2005

Drainage = of pleural=20 fluid in patients with inhalational anthrax: a critical need to be = anticipated=20 as part of combination therapy

The six=20 patients who survived inhalational anthrax after the attacks of = September 18-=20 October 9, 2001 all required drainage of the typically bloody fluid = around their=20 lungs (=93pleural fluid=94) either with a needle (=93thoracentesis=94) = or a larger chest=20 tube. The critical clinical importance and implications of this pleural = fluid=20 drainage, in conjunction with appropriate antibiotics, has not been = adequately=20 appreciated when preparing for anthrax attacks with large numbers of=20 casualties.

In fact,=20 five of the six (5/6) survivors of inhalational anthrax required TWO (2) = or more=20 pleural fluid drainage procedures, as summarized below (parenthesis = gives the=20 location where the mail-associated anthrax infection = occurred):

Survivor # 1=20 (Fla):

Two=20 (2) left-sided thoracentesis, then chest tube drainage. =

Survivor # 2=20 (DC):

Three=20 (3) thoracenteses required sequentially.

Survivor # 3=20 (DC):

Two=20 thoracenteses required sequentially

Survivor # 4=20 (VA):

One=20 thoracentesis required on hospital day 6.

Survivor # 5:=20 (NJ):

Two=20 (2) thoracenteses on the right side.

Survivor # 6=20 (NJ):

Two=20 (2) thoracenteses required on the right side, then chest = tube=20 drainage. Chest tube drainage also needed on left side on hospital = day=20 6

Drainage,=20 often repeated, could be therapeutic for at least two reasons: =

(1) removal=20 of toxin-producing anthrax bacteria in the fluid around the lung. When = the=20 organism was found in the pleural fluid by staining or culture, then the = criteria defining an =93empyema=94 is met and drainage of the infected = pleural fluid=20 (empyema) is the standard of care for any type of bacterial infection.=20

(2) The=20 bloody pleural effusions due to anthrax can be large, as well as = recurrent, and=20 could contribute to impaired lung function at a time when the anthrax = infection=20 is becoming a systemic infection. Subsequent progression of = systemic=20 anthrax disease to respiratory failure, or shock, would signal = progression from=20 the =93intermediate-progressive=94 stage of inhalational anthrax to the=20 prognostically-worse =93late-fulminant stage=94.

Of the five=20 patients who died in 2001 of inhalational anthrax, two had drainage of = pleural=20 fluid, but the other three also had pleural fluid found at = autopsy. =20 Autopsy data from the Sverdlovsk, Russia 1979 inhalational anthrax = casualties=20 also frequent reported pleural effusions, that were often large in = volume (~1,=20 700 ml).

In summary,=20 individual clinicians, including Emergency Medicine physicians, = Pulmonologists,=20 Critical Care Intensivists, and Infectious Disease physicians should = anticipate=20 the need to drain these anthrax-caused bloody pleural effusions, either = at the=20 time of initial evaluation or days after hospitalization and initiation = of=20 therapy.

Antibiotics=20 alone may not cure inhalational anthrax. In fact, the data from = 2001=20 argues that combination therapy is needed for inhalational anthrax,=20 specifically, pleural fluid drainage in conjunction with antibiotics.=20

Similarly,=20 public health, hospital, and national biodefense planners should = anticipate this=20 need for combination therapy of inhalational anthrax, including pleural = fluid=20 drainage by needle thoracentesis or chest tube, when reconsidering the = inventory=20 for the Strategic National Stockpile and the state of readiness in the = USA for a=20 catastrophic aerosol anthrax bioterrorism attack as anticipated by the = Cities=20 Readiness Initiative begun 12 months ago.

In fact,=20 other examples of specific readiness issues can be anticipated when = planning for=20 large-scale (e.g., aerosol) bioterrorism attacks involving one or more = US Cities=20 with other agents, such as pneumonic plague, smallpox, or avian-human = influenza=20 viruses that could also require altering national preparedness plans=20 now.

Daniel R.=20 Lucey, MD, MPH

Adjunct=20 Professor of Microbiology and Immunology

Georgetown=20 University School of Medicine

Director,=20 Center for Biologic Counterterrorism and Emerging Diseases

Department=20 of Emergency Medicine

Washington=20 Hospital Center

Washington,=20 DC

e-mail:=20 Daniel.R.Lucey@Medstar.net