Last Updated: 2023-07-07

Author(s): Anzengruber F., Navarini A.

ICD11: 1B97

Davaine 1863, 1865.

Mildew of the skin, pustula maligna.

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

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

  • Spygmy spores can remain undamaged for decades in hair, on the skin and in nature. The spores are resistant to heat and disinfectants. B. anthracis is absorbed via the skin, GI tract or lungs. Exotoxin release occurs and the first symptoms appear.
  • Incubation periods:
    • Skin anthrax: hours to 1 week
    • Respiratory anthrax: about 3-8 days, but shorter and longer incubation periods are possible (up to 56 days in humans, up to 100 days in monkeys)
    • Gastrointestinal anthrax: 1-3 days
    • Injection anthrax: approx. 1-3 days after injection

  • The symptomatology depends on the localisation and the site of pathogen ingestion
  • Skin anthrax:
    • Most common form (95%)
    • The pathogen penetrates the skin mostly in the area of minor injuries. At the site of entry, an erythematous macule develops, which in the course of time turns into a papule or pustule and finally a flaccid blister with serous and later haemorrhagic contents (pustula maligna). This is surrounded by a brown-reddish, violet area. In the course, a painless blackish scab develops from the blister (splenic gangrene)
    • In addition, there is a painful, locoregional lymph node adenopathy
    • After 7-10 days, there is scarring healing
    • Fever and reduced general condition
  • Respiratory anthrax (5%):
    • Inhalation of the spores
    • Biphasic course: First non-specific general symptoms such as fever, headache and pain in the limbs, then release of the exotoxins and transition into a severe clinical picture with sepsis and cardiovascular failure
  • Gastrointestinal anthrax (< 1%):
    • Ingestion of spores through food (especially contaminated milk, meat)
    • Abdominal pain, nausea, vomiting, loss of appetite, febrile temperatures and flatulence. In the course, bloody diarrhoea occurs. If there is a manifestation in the area of the mouth or throat (sore throat, febrile temperature, possibly dyspnoea and lymphadenopathy), it is referred to as oral pharyngeal anthrax [RKI]. Transition to sepsis is possible
  • Injection anthrax:
    • Comes from an injection contaminated with anthrax spores (contaminated substance or needle). In this case, a marked erythematous, oedematous, soft tissue infection develops. Complications may include compartment syndrome and necrotising fasciitis. CNS involvement is possible 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.

  • Anamnesis
  • Clinical
  • Collection of 2 blood cultures (each aerobic and anaerobic)
  • Bact. smear from blister fluid or from below the scab (Gram stain and PCR)
  • EDTA blood for PCR
  • CAVE: There is a risk of carryover with specimen biopsies, so they are not indicated
  • For pulmonary anthrax: sputum or bronchial lavage
  • For meningitis: cerebrospinal fluid (CSF) puncture
  • For gastrointestinal anthrax: stool sample

Sepsis with meningitis and splenic involvement (especially in immunosuppression)


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

Lethality: cutaneous anthrax 10-40% , good prognosis with timely treatment.

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