Anthrax

Davaine 1863, 1865.

Anthrax of the skin, Pustula maligna, Woolsorter’s Disease, Ragpickers’ Disease.

Notifiable zooanthroponosis caused by Gram-positive, aerobic, rod-shaped Bacillus anthracis.

• Inoculation
• Direct contact, inhalation or via the GI tract.
• Particularly at risk are veterinarians, farmers, foresters, hunters, butchers, knackers, workers in contact with leather (occupational disease). Anthrax can also occur in heroin addicts.
• In 2012, 12 cows died of anthrax in Saxony-Anhalt, but anthrax has become very rare in Central Europe due to vaccinations and controls. However, in poorer countries (the Balkans, Southern Europe, Central Asia and Africa) the disease and an increased contamination rate still occur.
• Used as a biological weapon, 22 people in the USA were diagnosed with anthrax in 2001 and 11 patients were diagnosed with pulmonary anthrax. Of these, 5 died who had contact with anthrax spores sent by post.
• A special form is the Bacillus cereus biovar anthracis, which draws the chromosomal DNA from Bacillus cereus, but the two virulence plasmids from B. anthracis.
• Reservoir:
• Soil, cattle, sheep, horses, pigs and poultry.

• Anthrax spores can remain in hair, on the skin and in nature for decades without damage. The spores are resistant to heat and disinfectants. B. anthracis is absorbed through the skin, GI tract or lungs. Exotoxin is released and the first symptoms appear.
• latent periods
• Anthrax: Hours to 1 week.
• Lung anthrax: approx. 3-8 days, but shorter and longer incubation times are possible (up to 56 days in humans, up to 100 days in apes).
• Gastrointestinal anthrax: 1-3 days.
• Injection anthrax: approx. 1-3 days after injection.

• The symptoms depend on the location and the location of the pathogen uptake.
• Skin anthrax:
• Most common form (95%).
• The pathogen usually penetrates the skin in the area of minor injuries. At the site of entry, an erythematous macula develops, which then develops into a papule or pustula and finally a flaccid bladder with serous and later haemorrhagic content (Pustula maligna). It is surrounded by a reddish-brown, violet area. In the course of the procedure, a painless blackish scab (anthrax carbuncles) develops from the bladder.
• Painful, locoregional lymph node adenopathy is also evident.
• Scarred healing occurs after 7-10 days.
• Fever and reduced general condition.
• Pulmonary anthrax (5%)
• Inhalation of the spores. 
• Biphasic course: First unspecific general symptoms such as fever, headache and aching limbs, then release of exotoxins and transition to a severe clinical picture with sepsis and cardiovascular failure.
• Gastrointestinal anthrax (< 1%)
• Absorption of spores by food (especially contaminated milk, meat).
• Abdominal pain, nausea, vomiting, loss of appetite, febrile temperatures and flatulence. Bloody diarrhoea develops in the course of time. If there is a manifestation in the area of the mouth or throat (sore throat, febrile temperature, possibly dyspnea and lymphadenopathy), it is called mouth throat Anthrax [Robert Koch Institute]. Transition to sepsis is possible.
• Anthrax by injection
• Occurs through an injection contaminated with anthrax spores (contaminated substance or needle). In this case a pronounced erythematous, edematous, soft tissue infection develops. Complications include compartment syndrome and necrotizing fasciitis. The CNS may be involved as a complication. Alternatively, abdominal symptoms may occur. Clinically, there is no possibility of differentiation from other soft tissue infections. The anamnesis is indicative here.

• Medical history
• Clinic
• Collection of 2 blood cultures (aerobic and anaerobic)
• Bacterial smear from blister liquid or from below the scab (gram staining and PCR).
• EDTA blood for PCR.
• CAVE: There is a risk of carryover in sample biopsies, which is why they are not indicated.
• In case of pulmonary anthrax: sputum or bronchial lavage.
• For meningitis: cerebrospinal puncture.
• For gastrointestinal anthrax: stool sample.

Sepsis with meningitis and spleen involvement (especially in immunosuppression).

• Vaccination for high-risk individuals.
• Post-exposure prophylaxis: #Ciprofloxacin 2x 500 mg daily recommended for 60 days.
• BioThrax®, an acellular vaccine, can be used for soldiers and high-risk individuals.

Mortality: anthrax 10-40%, good prognosis if treated in time.

1. Booth MG, Hood J, Brooks TJ, Hart A, Health Protection Scotland Anthrax Clinical N. Anthrax infection in drug users. Lancet 2010;375:1345-6.
2. Inglesby TV, O'Toole T, Henderson DA, et al. Anthrax as a biological weapon, 2002: updated recommendations for management. JAMA 2002;287:2236-52.
3. Leendertz FH, Ellerbrok H, Boesch C, et al. Anthrax kills wild chimpanzees in a tropical rainforest. Nature 2004;430:451-2.
4. Ringertz SH, Hoiby EA, Jensenius M, et al. Injectional anthrax in a heroin skin-popper. Lancet 2000;356:1574-5.
5. Klee SR, Brzuszkiewicz EB, Nattermann H, et al. The genome of a Bacillus isolate causing anthrax in chimpanzees combines chromosomal properties of B. cereus with B. anthracis virulence plasmids. PLoS One 2010;5:e10986.
6. Hoffmaster AR, Ravel J, Rasko DA, et al. Identification of anthrax toxin genes in a Bacillus cereus associated with an illness resembling inhalation anthrax. Proc Natl Acad Sci U S A 2004;101:8449-54.
7. Meselson M, Guillemin J, Hugh-Jones M, et al. The Sverdlovsk anthrax outbreak of 1979. Science 1994;266:1202-8.
8. Henderson DW, Peacock S, Belton FC. Observations on the prophylaxis of experimental pulmonary anthrax in the monkey. J Hyg (Lond) 1956;54:28-36.
9. Sirisanthana T, Brown AE. Anthrax of the gastrointestinal tract. Emerg Infect Dis 2002;8:649-51.
10. Biederbick W, Fock R, Guttler K, Veit C. [Infections by Bacillus anthracis]. Dtsch Med Wochenschr 2002;127:809-14.
11. Brachman PS. Inhalation anthrax. Ann N Y Acad Sci 1980;353:83-93.
12. Grunow R, Verbeek L, Jacob D, et al. Injection anthrax--a new outbreak in heroin users. Dtsch Arztebl Int 2012;109:843-8.
13. Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl J Med 1999;341:815-26.
14. Bernard H. et al. Drogenkonsum: Bacillus anthracis in Heroin? Dtsch Arztebl 2010; 107(17).
15. Salzberger, B. (2012). Injektions-Anthrax (Milzbrand). Deutsche Gesellschaft für Hygiene und Mikrobiologie (DGHM). Retrieved 13 October 2015, from http://www.dghm.org/diagnostikqualitaetssicherung/m_323
16. Bernard H: Drogenkonsum: Bacillus anthracis in Heroin? Deutsches Arzteblatt-Arztliche Mitteilungen-Ausgabe B 2010; 107(17): p. 703
17. EMA/CHMP Guidance document on use of medicinal products for the treatment and prophylaxis of biological agents that might be used as weapons of bioterrorism. (2014). European Medicines Agency. Retrieved 13 May 2016, from http://www.ema.europa.eu/docs/en_GB/document_library/Regulatory_and_procedural_guideline/2010/01/WC500049399.pdf