Industry-related Outbreak of Human Anthrax - Letters - Letter to the Editor

Emerging Infectious Diseases, Dec, 2003 by John A. Jernigan, David S. Stephens, David A. Ashford, Bradley A. Perkins

To the Editor: In his letter, Industry-related Outbreak of Human Anthrax, Massachusetts, 1868 (1), Dr. Macher suggests an additional reference to cases of industry-related anthrax that occurred in the United States in the 1800s. Our paper exclusively addressed bioterrorism-related inhalational anthrax (2). In our introductory paragraph we referred to woolsorter's disease and ragpicker's disease, terms used to describe textile industry related inhalational anthrax rather than cutaneous disease (3,4). The citation to which Dr. Macher refers describes eight patients that had cutaneous lesions consistent with cutaneous anthrax; some also had evidence of secondary bacteremic dissemination (5). Dr. Macher suggests that the symptoms of chest distress, chest pain, dyspnea, and tachypnea described in some of the patients are evidence of "mediastinal involvement." However, these symptoms may be consistent with bacteremic dissemination of Bacillus" anthracis. and their presence is not sufficient evidence to conclude that these patients had hemorrhagic mediastinal lymphadenopathy, the pathologic hallmark of inhalational anthrax. In addition, the observed case-fatality rate of 25% in these patients is consistent with untreated cutaneous anthrax and contrasts sharply with the expected case-fatality rate of >85% for untreated inhalational disease (4,6).

John A. Jernigan, *

David S. Stephens, *

David A. Ashford, *

and Bradley A. Perkins *

* Centers for Disease Control and

Prevention, Atlanta, Georgia, USA

References

(1.) Macher A. Industry-related outbreak of human anthrax: Massachusetts, 1868. Emerg Infect Dis 2002;8:1182.

(2.) Jernigan J, Stephens D, Ashford D, et al. Bioterrorism-related inhalational anthrax: the first l0 cases reported in the United States. Emerg Infect Dis 2001;7:933-44.

(3.) LaForce F. Woolsorter's disease in England. Bull N Y Acad Med 1978;54: 956-63.

(4.) Brachman P. Inhalation anthrax. Ann N Y Acad Sci 1980;353:83-93.

(5.) Stone S. Cases of malignant pustule. Boston Med Surg J 1868;I (N.S.):19-21.

(6.) Dixon T, Meselson M, Guillemin J, Hanna P. Anthrax. N Engl J Med 1999;341: 815-26.

Address for correspondence: John Jernigan, Centers for Disease Control and Prevention, 1600 Clifton Rd., MS E68, Atlanta, GA 30338, USA; fax: 404-498-1244; email: jqi9@cdc.gov

In Reply: Jernigan et al. state that they exclusively addressed cases of inhalational anthrax in their 2001 report. However, I question whether their patient 8, a mail sorter with a "healing scab on the anterior neck," can be classically characterized as a pure case of inhalational anthrax.

On October 14, 2001, a 56-year-old female mail sorter (patient 8) in New Jersey became ill with vomiting and diarrhea, followed the next day by chills and fever. The vomiting and diarrhea improved, but during the next 2 days, she had shaking chills, fever, headache, and fatigue. A non-produtve cough developed, along with mild shortness of breath and anterior chest pain on inspiration. On October 19, with persistent fever and worsening chest pain, she went to a local emergency room. She appeared ill with increased respiratory effort and had a 0.5- to 1.0-cm healing scab on the anterior neck. A computed tomographic scan of the chest on October 22 demonstrated mediastinal and cervical lymphadenopathy (1).

In 1942, Severn reported a fatal case of pulmonary/meningeal anthrax in a 17-year-old woman whose cutaneous (point-of-entry) lesion had healed (2). The patient had received no specific treatment for anthrax, as such was not even suspected before death; nor had any form of chemotherapy been instituted. Up to 10 days before her illness, the woman had been working in a modern South Wales brush factory. Two days before ending her employment, she had what her parents described as a boil on the middle phalanx of the second finger of the right hand from the center of which her father extracted a bristle that had entered the finger in the course of her work. The lesion subsequently healed without medical aid. Her final illness (high temperature and severe headache) began 12 days after this incident, the patient being quite well in the interval.

An autopsy was performed by Dr. J. Gough, a pathologist at the Cardiff Royal Infirmary. Each pleural cavity contained blood-stained fluid: one half pint on the left side and three quarters pint on the right. The pia-arachnoid was extremely congested over the hemispheres, with subarachnoid hemorrhage on the upper and lateral aspects and along the Sylvian fissures. The brain showed an acute hemorrhagic inflammation of the pia-arachnoid over the hemispheres. The subjacent brain showed an acute inflammation of perivascular distribution in the gray matter. Similar inflammation was present in the basal ganglia and cerebellum. In the lungs, tissues were destroyed in some hemorrhagic areas. From the meninges, brain, spleen, and blood a spore-bearing aerobe was grown in pure culture. The same organism was grown from the lung. The spore-bearing organism was pathogenic for the guinea pig and mouse and identified as Bacillus anthracis. The woman had been employed in sorting horsehair and pig bristle imported mainly from China and South America.

Samples of materials she sorted were tested for bacteria by Dr. V.D. Allison, Ministry of Health, who reported that the seven different batches of suspected horsehair and bristle submitted were heavily contaminated with aerobic spore-bearing organisms, and from one batch of mixed horsehair, he isolated a colony of typical B. anthracis that was lethal to a guinea pig.

The clinical history suggests that the portal of entry of the infection was the finger that healed spontaneously, as there was no evidence of this lesion at autopsy (2). I propose that Jernigan et al.'s patient 8 with inhalational anthrax may have also had a cutaneous portal-of-entry infection by the spores of B. anthracis.

Jernigan et al. also state that mediastinal involvement does not develop in patients with cutaneous anthrax. In 1918, Gilmour and Campbell (a pathologist) reported the cases of two men who contracted anthrax from shaving brushes contaminated with B. anthracis; patient 2 had cutaneous anthrax with mediastinal involvement. He was admitted to Bramshon Military Hospital, Canada, on February 27. On February 22, he had procured a new shaving brush from Quartermaster stores and used it for the first time on February 25; while shaving, he cut his left cheek slightly, causing free bleeding. Toward evening he began to feel poorly; he felt ill during the night. On the morning of February 26, he shaved again and reopened the wound, which again bled freely. Shortly before noon, his face began swelling very rapidly around the cut, down the side of his neck, and in front and behind the ear. During the afternoon he felt worse, had chills, and had a severe headache. He had difficulty swallowing, and the swelling of the neck and face was increasing. During the night, he had great difficulty in swallowing and breathing; he felt as if he were going to choke. He had a severe headache, nausea, vomiting, and chills. On February 27, his temperature was 38.9[degrees]C and pulse 140. The left side of his lace and neck were very swollen; the swelling extended down over the sternum. Respirations were shallow and impaired. A smear from the malignant pustule on the left cheek demonstrated anthrax bacilli. On February 28, the patient lapsed into a coma and died. A postmortem examination showed that "mediastinal tissues were extremely edematous" (3).