Anthrax

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Anthrax is a bacterial disease caused by the spore forming Bacillus anthraces, a gram positive, rod- shaped bacterium. It is a zoonotic disease whereby man is infected directly through contact with  infected hides or inhalation of spores in the lungs or ingestion of infected meat. It can be manifest on  the  skin  (Cutaneous  Anthrax)  in  the  lungs  (Pulmonary/Inhalation  Anthrax),  and/or  intestinal  (Gastrointestinal Anthrax and Oropharyngeal anthrax) or CNS (Meningeal Anthrax). 

Clinical Presentation  Cutaneous Anthrax 

  • Itching
  • Pruritic papule or vesicle
  • Characteristic depressed black eschar surrounded by moderate to severe edema
  • A malignant pustule
  • Pyrexia

Inhalation Anthrax 

  • Mild inhalation Anthrax 
    • Cough, Fever, Fatigue, Myalgia, can resemble a viral respiratory illness, pulmonary and gastrointestinal signs may occur together 
  • Severe inhalation Anthrax 
    • Diaphoresis, Stridor, Dyspnea, Hypotension, Acute respiratory distress
    • These patients may develop sepsis accompanied by cyanosis, shock, and hemorrhagic pneumonia.  Hemorrhagic pleural effusions often develop. 

Gastrointestinal Anthrax 

  • Fever, Abdominal pain, Vomiting, Diarrhea Bloody stool.

Oropharyngeal anthrax 

  • Signs of oropharyngeal anthrax may include dysphagia with posterior oropharyngeal necrotic ulcers,  Unilateral neck swelling, Cervical adenopathy, Edema, Pharyngitis fever

Meningeal Anthrax 

  • Hemorrhagic meningoencephalitis that involves both 
    • Deep brain parenchymal hemorrhagic lesions
    • Infection of the cerebrospinal fluid (CSF) in the subarachnoid space

Case Definition 

Suspected Case: Any person with acute onset illness characterized by several clinical forms which are: 

  • Cutaneous  form: Any person with skin lesion evolving over 1 to 6 days from a papular through a vesicular stage, to a depressed black eschar invariably accompanied by oedema that may be mild to extensive. 
  • Gastro-intestinal: Any person with abdominal distress characterized by nausea, vomiting, anorexia and followed by fever 
  • Pulmonary (inhalation):  Any  person  with  brief  prodromal  resembling  acute  viral respiratory  illness,  followed  by  rapid  onset  of  hypoxia,  dyspnoea  and  high  temperature,  with X-ray evidence of mediastinal widening 
  • Meningeal: Any person with acute onset of high fever possibly with convulsions, loss of consciousness,  meningeal  signs  and  symptoms;  commonly  noted  in  all  systemic  infections, but may present without any other clinical symptoms of anthrax. 

AND 

Has  an  epidemiological  link  to  confirmed  or  suspected  animal  cases  or  contaminated  animal products

Confirmed case: A confirmed case of anthrax in a human can be defined as a clinically compatible case of cutaneous, inhalational or gastrointestinal illness that is laboratory-confirmed by: 

  1. Isolation of B. anthracis from an affected tissue or site; or 
  2. Other  laboratory  evidence  of  B.  anthracis  infection  based  on  at  least  two  supportive laboratory tests

Laboratory Investigation  

  • Isolation of Bacillus anthracis from a clinical specimen (e.g. blood, lesions, discharges) 
  • Demonstration  of  B.  anthracis  in  a  clinical  specimen  by  microscopic examination  of  stained  smears  (vesicular  fluid,  blood,  cerebrospinal  fluid,  pleural fluid, stools)  
  • Positive  serology  (ELISA,  Western  blot,  toxin  detection,  chromatographic assay, fluorescent antibody test)
  • Detection of nucleic acid by PCR

Other supporting tests 

  • Measurement of antibodies or toxin in blood 
  • Chest X-ray
  • Computerized tomography (CT) scan
  • Detection of B. anthracis by nucleic acid test (NAT) covering the genes coding for capsule and virulence factors

Prevention: Post Exposure Prophylaxis 

A: Initial 10-day exposure: ciprofloxacin (PO) 500 mg 12hourly for 5 days or doxycycline 100mg (PO) 12 hourly  (or,  if  pathogens  are  documented  to  be  susceptible  phenoxymethyl  penicillin may be used)

  • Adults: phenoxymethyl penicillin (PO) 250-500 mg 6 hourly
  • Children 1-5 years: phenoxymethyl penicillin (PO) 125 mg 6 hourly. 
  • 6-12 years: phenoxymethyl penicillin (PO) 250 mg 6 hourly 48 hours’ exposure:  

OR 

S: clindamycin (PO) 150 to 300 mg 6 hourly for 5days 

OR  

S: levofloxacin (PO) 500 mg 12hourly for 5 days are alternative antimicrobial prophylaxis to the local population within 48 hours of the initial exposure  

Pharmacological Treatment

A: benzylpenicillin (IV) 0.6 MU 6 hourly until local oedema subsides then continue with 

A: phenoxymethyl penicillin (IV) 250 mg 6 hourly for 7 days 

If not responding, change to  

A: doxycycline (PO) 200mg initial dose then 100mg 12 hourly for 7 days  

OR  

A: ciprofloxacin (PO) 500mg 12 hourly for 7 days 

AND  

A: paracetamol (PO) 15mg/kg 8 hourly for 5days 

In severe forms ADD  

Dexamethasone (PO) 0.6 mg/kg per day in divided doses every 8 hours for 4 days 

Public Health Control Measures 

  • Standard infection control precautions (IPC) should be used when managing patients with particular attention to body fluid spills, as organisms which remain on surfaces may form  spores which are infectious 
  • Personal  protective  equipment  should  be  used  in  situations  where  there  is  potential  for splashes and inoculation injuries.  
  • Mobilize the community for early detection and care
  • Ensure proper burial or cremation (if practiced) of dead bodies (humans and animals) 
  • Conduct community education on the disease symptoms and signs, early  reporting/seeking  of  medical  care,  disease  transmission  and  prevention,  application  of  infection prevention and control for home care setting  
  • Conduct active search for additional cases that may not come to the health care setting  (older  women  or  small  children  patients,  for  example)  and  provide  a  door  to  door  information about prevention and when to seek care
  • Ensure adequate collaboration with other sectors such as livestock, agriculture,  environmental and sanitation, to ensure appropriate interventions are addressed
  • Request additional help from district/regional/national levels as needed