Anthrax - a guide for doctors and patients

ANTHRAX-a question may come from area

Anthrax - a guide for doctors and patients

Introduction
Anthrax is a bacterial disease. It is caused by a bacteria that belongs to the same family as E. coli. called Enterobacteraciae. It is not a virus. Unfortunately, it has become a recent threat as it can be used for biological warfare.

The bacteria
It is a rod shaped bacteria with rounded edges. It cannot be seen by the naked eye. Labs need a microscope to see it.

When doctors check or screen for bacteria, they stain the specimens commonly with a simple technique called gram staining. There are very few bacteria that are rod shaped and test positive on this test. Fortunately - for diagnostic purposes, anthrax bacteria test positive. This immediately raises a flag.

Modes of spread
It is spread by its spores that can survive harsh natural conditions for years.

It may be transmitted by infected or contaminated animals and animal products, insect bites, inhalation or ingestion.

Spread of anthrax usually does not take place from person to person except where the patient has skin lesions. It could however take place by handling contaminated articles.

In the Florida cases, it seemed to be transmitted by exposure from spores that were sitting on the computer keyboard (I am looking at my own keyboard as I type this).

I do not want people to panic because Florida is currently one of the most prepared states in the United States to tackle this problem. In my own office, we have at least a hundred doses of medicines that tackle anthrax. I am sure other doctors are prepared too.

Types of disease
It is seen in three main forms.

Skin (cutaneous), intestinal (gastrointestinal), and its most dangerous form - lung infection or pneumonia (pulmonary).

Cutaneous anthrax is the most common manifestation of infection with B. anthracis. Inhalation (pulmonary) anthrax occurs in persons working in certain occupations where spores may be forced into the air from contaminated animal products, such as animal hair processing. Occupational risk groups include those coming into contact with livestock or products from livestock, e.g., veterinarians, animal handlers, abattoir workers, and laboratorians.

A patient with this form of anthrax may present with a blister with central denting and surrounding swelling that cannot be indented.

This is full of the antrax bacteria, making it highly infective as it sheds a lot of bacteria.

The intestinal form shows up as diarrhea and fever. Fortunately the commonest family of drugs used to treat this type of illness even in the non-anthrax condition treats anthrax as well.

The lung form of the disease begins abruptly with high fever and chest pain. It quickly turns into a bleeding type of illness and is frequently fatal. These cases are not highly infective.

If untreated, anthrax in all forms can lead to the bacteria entering the bloodstream and quickly - death. Early treatment of cutaneous (skin) anthrax is usually curative, and early treatment of all forms is important for recovery. 25% to 75%. of patients with gastrointestinal (intestinal) anthrax will die. Almost 90 - 100% of those with lung anthrax will die.

Preventing disease and its spread
Anthrax in the veterinary world commonly affects herbivorous animals. Human immunity against anthrax is higher than the herbivores. This does not mean that vegetarians are any less immune to the bacteria than non-vegetarians.

We must identify what common things that come in contact with many hands in a day's time and be cautious about their safety. I am going to list a few here.

Currency notes and coins, Paper files and inter office mail envelopes, Card swiping areas, e.g. time card machines and credit card machines, Support bars into a bus, Door knobs, Water fountains, Gas station vending handles, Vending machines, Public telephones, Perfume testers in a mall, Coins and tokens for a slot machine, Buttons at traffic signals used by pedestrians to get access, Library computers, books and video tapes, Rented video tapes, etc, Objects in churches that many people touch, etc.

Please wash your hands before you touch your mouth or nose after you touch something that may be contaminated. Avoid opening letters if you have a wound on your hands.

Treatment
Early treatment is vital. Therefore you do not need to hoard a full course of the antibiotics that are effective but just the first dose alone.

Many good antibiotics are available that are approximately equally useful but Once symptoms of the lung form appear, fatality is high inspite of treatment.

Levaquin, Cipro, Tequin, avelox are good medicines that could be used.

Penicillin too is useful as are many other antibiotics.

Most commonly, the skin form comes along and one can treat that very effectively.

What should your doctor do?
Having been a licensed practitioner for over 10 years, practice of reasonable and economical medicine has now become second nature to me. I am not trying to say that what is outlined here is perfect but these guidelines will certainly help those who have not put in a lot of thought into this. If other doctors also put in thought into this, they will come out with similar answers.

If a patient wants to keep antibiotics at home for him and his family, he should only be offered dosing for 24 hours.

This means 2 tablets of Ciprofloxacin (Cipro) or 1 tablet of Levaquin or Avelox or Tequin. He should be told that this should be given if suspicion is high and the patient should be examined by a doctor soon.

Giving out long courses are going to create a shortage and thus further panic in the community.

If the doctor has a suspicion of anthrax in the patient, he should immediately draw and keep blood from the patient and then administer the first dose of the antibiotic immediately.

If it is a skin lesion that the doctor sees, he should take a scraping from the skin lesion and send part of it for a Gram stain and another part for culture. Antibiotic of course should be given immediately.

Doctors also should try to avoid use of these antibiotics in conditions where other antibiotics are equally effective.

What does it mean that the cases are due to genetically un-altered bacterial strains?

Since the cases had the above type of strain, it is unlikely that these are from terrorists. It is more likely that someone who has animals got that strain and now has mailed the stuff to different people across the country. One should look through veterinary records and match up people who owned animals that died of anthrax in the Tampa-bay area. I could certainly be wrong but I rarely am.

How concerned should we be about the future
Not very. I am not an astrologer nor a psychic but seeing that these cases have been from unaltered bacteria, I feel that these are not well prepared terrorists left around. Had this attack come from well prepared terrorists, we would have seen very communicable, genetically altered anthrax strains. They would have used their biowarfare material already within this one month. Regardless, almost all doctor's offices are well prepared with antibiotics.

Vaccine
In the civilian world, the health departments are most likely going to be the first to recieve vaccine supplies. I think that many of us doctors should volunteer and offer to give out the vaccines if that is decided by the government. Our clinic has already registered with the health department for this purpose.

**A 7-year-old white female is brought to your office because of a 3-day history of an increasingly clumsy gait. The mother noted that she first observed the problem 2 days earlier when her daughter climbed out of the bathtub and had difficulty standing up while being dried off. At the time she thought the child was just playing. The next day the child seemed better and went to school, but was sent home because she was having difficulty on the playground and said that 'it was hard' going up the stairs. The child had a minor upper respiratory illness, as did other family members, but otherwise was not particularly sick. However, on the morning of this office visit, the child was unable to stand up when she got out of bed and had difficulty using her spoon to eat her cereal. She had no difficulty swallowing.

Examination is within normal limits, except for a slightly runny nose which drains clear, watery mucus. There is no evidence of ear infection or sinusitis. She has profound weakness (but not total paralysis) of the lower extremities, and to a lesser extent, the upper extremities. There is no sensory deficit and no difficulty with urination.

never having had any similar symptoms. The family lives in a rural area near woods; she has two older brothers. Family pets include two dogs, a cat, and a parakeet. No family members or animals are sick. Blood counts, chemistries, urinalysis, cerebrospinal fluid, a CT scan of the head, and a chest roentgenogram are all normal. A tick is found in her scalp.

Which one of the following statements is true concerning this patient's condition?



a. The most likely diagnosis is tick paralysis; the tick should be removed and the patient followed
b. Since the patient had progressive symptoms for 3 to 4 days, removing the tick at this point will probably not lead to total recovery
c. Tick paralysis is fatal to the majority of patients
d. The paralysis is caused by a toxin produced by Babesia microti
e. Treatment includes physical therapy and broad-spectrum antibiotics

A

With all laboratory tests being normal, finding a tick on this patient strongly suggests that the diagnosis is indeed tick paralysis. Untreated, tick paralysis can have a 10% to 12% mortality rate. The paralysis is thought to be caused by a neurotoxin produced by the tick's salivary glands, and not an infection. Recovery is usually prompt when the tick is removed, and neither physical therapy nor broad-spectrum antibiotics would be necessary to hasten recovery. Babesia microti causes babesiosis, and paralysis is not part of its symptom complex.

**Which one of the following statements is most accurate concerning juvenile rheumatoid arthritis?

a. Fever is a rare systemic manifestation
b. Ten years after the onset of disease, most patients have excellent functional status
c. Most patients have a permanent deformity of at least 1 extremity
d. The disease is characterized by lifelong recurrences
e. Most patients require corticosteroid treatment

B

At least 50% of patients followed for up to 15 years have complete remission of juvenile rheumatoid arthritis, and 70% regain normal function. A few patients are left with crippling joint deformities, but 75% have no significant residual deformity. Systemic-onset disease is accompanied by high fever, rheumatoid rash, polyarthritis, and other systemic manifestations.

**You see a 2-week-old Hispanic female in your office because of a rash in the diaper area. The rash is intensely red, has sharp borders with satellite pustules and papules beyond the borders, and involves the inguinal folds.

The most likely cause of the rash is

a. primary irritant dermatitis
b. atopic dermatitis
c. psoriasis
d. seborrheic dermatitis
e. candidal infection

E

The rash described is typical of a candidal infection, one of the most common causes of diaper rash. The rash of seborrheic dermatitis starts in the skin folds and extends to convex surfaces, with a poor demarcation from surrounding skin. It is characterized by yellow, greasy scales, and may involve other sites such as the scalp, face, and retroauricular areas. When psoriasis begins in infancy it usually starts in the area of greatest trauma, which is the diaper area. The typical well-demarcated plaques may not appear scaly because of moisture and maceration.
Atopic dermatitis usually begins after 2 months of age and is characterized by marked pruritus and secondary bacterial infections with oozing and crusting. Primary irritant dermatitis usually begins after 3 months of age and appears on convex surfaces with sparing of the folds. The involved skin is erythematous and has a shiny appearance. It is caused by trapped moisture and friction at sites of contact with the diaper.

**A 4-year-old white female is brought to your office by her parents because she swallowed a penny 1 hour ago. Examination of the pharynx is normal. A radiograph reveals a coin in the area of the gastric antrum.

Which one of the following would be most appropriate?

a. Immediate consultation with an otolaryngologist
b. Immediate consultation with a gastroenterologist
c. An abdominal radiograph in 12 hours
d. An abdominal radiograph in 24 hours
e. Advising the parents to monitor stools for passage of the coin and to report any abdominal symptoms

E

Many children are exposed to unnecessary radiation and surgery after swallowing coins. It is recommended that all affected children have a single initial film of the chest and neck. Unless they have symptoms, patients with coins below the cardia should require no follow-up other than reassurance.

**You see a white male who is concerned because he is the shortest boy in his class. His age is 14.3 years and his parents are of normal height. He has a negative past medical history and no symptoms. On physical examination you note that he is 151 cm (59 in) tall. The average height for his age is 165 cm. His weight is 43 kg (95 lb). His sexual maturity rating is 3 for genitalia and 2 for pubic hair. A wrist radiograph shows a bone age of 12.2 years (the average height is 152 cm for this age).

On the basis of this evaluation you can tell the boy and his parents that


a. he should have a growth hormone stimulation test
b. his adult height will be below average
c. his sexual development is about average for his age
d. he will begin to grow taller within a year or so
e. an underlying nutritional deficiency may be the cause of his short stature

D

Constitutional growth delay, usually genetic in origin, consists of delayed, but eventually normal, growth in adolescents. If evaluation of the short adolescent boy reveals no evidence of chronic disease, if his sexual maturity rating is 2 or 3, and if his height is appropriate for skeletal age, he can be told without endocrinologic testing that he will begin to grow taller within a year or so. Adult height may be below average, but cannot be predicted reliably. Average sexual maturity ratings for a boy of 14.3 years are 4 for genitalia and 3 to 4 for pubic hair. The history and physical examination would have given clues to any illnesses or nutritional problems.

**You examine a full-term infant who weighs 2800 g (6 lb 3 oz). His Apgar scores are 8 and 9, and your initial evaluation reveals no abnormalities. The mother is not your patient and you note from her chart that she had no prenatal care. Approximately 12 hours after delivery you are notified that the mother is positive for human immunodeficiency virus (HIV).

Which one of the following is the appropriate management of the newborn?

a. Begin zidovudine (AZT, Retrovir) prophylaxis immediately
b. Begin zidovudine prophylaxis only if the infant's HIV status is positive
c. Encourage breastfeeding to promote maternal antibody transfer
d. Provide routine newborn care

A

HIV transmission from mother to newborn may occur during pregnancy, labor, or delivery, or postnatally via breastfeeding. The mother-to-infant transmission rate is approximately 20% to 30%. Zidovudine prophylaxis beginning during pregnancy and continuing postnatally for the first 6 weeks of the infant's life has been shown to reduce the transmission rate. Although the most significant benefit occurs if prophylaxis is begun during pregnancy, there is still some potential benefit if it is started within 24 hours after birth.