21 January 2010

14 Anthr= ax cases (7 fatal) in Scotland include some with necrotizing fasciitis and Rx with Anthrax Immunoglobulin

The number of injection drug (heroi= n) users in Scotland with laboratory-confirmed Bacillus anthracis infection is currently 14, with seven deaths. The Health Prot= ection Scotland (HPS) website, updated on a daily basis and including outbreak management and treatment information, can be found at: http://www.hps.scot.= nhs.uk/anthrax/index.aspx

= A rapid communication in the 14 January issue of Eurosurveillan= ce by Ramsay and colleagues from the UK reported that at least some of the patients presented with the unusual manifestation, for anthrax, of necrotizing fasciitis. http://www= .eurosurveillance.org/ViewArticle.aspx?ArticleId=3D19465<= span style=3D'font-size:9.0pt;mso-bidi-font-size:13.0pt;font-family:Arial;mso-bi= di-font-family: Verdana'>. In addition, at least two of the patients presented with hemorrh= agic meninigitis or subarachnoid hemorrhage (SAH). The paragraph from this publication citing the clinical presentation is quoted in full below, given= the unusual form of anthrax being seen in these patients:

“Generally, the ca= ses have presented with inflammation or abscesses related to sites of heroin injection. Symptoms began between one and two days or longer after injectio= n of heroin and admission to hospital generally followed within four days. Local= ized lesions developed into necrotising fasciitis in a number of cases, some of = whom died. The fatal cases in Glasgow (three men and one woman) died between thr= ee and seven days after admission. Cellulitis with very marked oedema has been noted in limbs with infection sites in a number of these cases. In a few ca= ses the presentation has been of patients in advance stages of systemic sepsis = some of whom died within hours. At least two cases presented with symptoms thoug= ht of at initial assessment as suggestive of a sub-arachnoid haemorrhage or haemorrhagic meningitis. Others presented with relatively localized lesions which have not progressed. The range of presentations is therefore wide and inconsistent”.

In terms of therapy, in addition to antibiotics this paper by Ramsay et al., stated that anthrax immunoglobulin (AIG) had been made available via the US CDC: “Acknowledgem= ents:  The role of CDC in providing = advice and support by way of personnel and a supply of the anthrax immunoglobulin (AIG) is gratefully acknowledged, in particular Dr. Nicki Pesik and Dr. The= resa Smith regarding use of the AIG and colleag= ues Dr. Sean Shadomy and Dr. Kendra Stauffer in support”.

The working case definitions for “confirmed”, “probable” and “possible” anthrax cases for this particular outbreak have = been defined on the Health Protection Scotland website as a pdf at: http://www.hps.scot.nhs.= uk/anthrax/documents/case-definition-anthrax-outbreak-v5.pdf

Further clinical details and specific treatments including surgical, antibiotic combinations, and anthrax immunoglobulin (AIG) are keenly awaited, even more so now that a similar patient has been reported from Germany in the same 14 January issue of Eurosurveillance.

Daniel R. Lucey, MD, MPH

EROne Institute, Department of Emergency Medicine

Washingt= on Hospital Center

Adjunct Professor of Microbiology and Immunology

Georgeto= wn University = Medical Center

Washingt= on, DC

www.BePast.org

Drafted in Lima, Peru