1. Classic Presentation of Inhalational Anthrax Initial phase -Malaise, fatigue, fever, myalgias, non-productive cough -1-4 days Fulminant phase -Respiratory distress, diaphoresis, shock -Death usually follows 1-2 days after onset of fulminant phase

2. Inhalational Anthrax Cases, 2001 (n=10) Median age Male Median incubation (when known,n=6) Median duration of symptoms prior to presentation 56 years (range 43-73) 7 (70%) 4 days (range 4-6) 3.5 days (1-7 days)

3. Symptoms of Inhalational Anthrax Cases (n=10) Fever, chills10/10 Sweats 7/10 Fatigue/malaise10/10 Cough 9/10 Nausea/vomiting 9/10 Dyspnea 8/10 Chest discomfort 7/10 Myalgias 6/10 Headache 5/10 Confusion4/10 Abdominal pain3/10 Sore throat2/10 Rhinorrhea1/10

4. Initial Physical Findings in Patients with Inhalational Anthrax (n=10) Fever 7/10 Tachycardia 8/10 Hypotension 1/10

5. Initial Laboratory Findings in Patients with Inhalational Anthrax (n=10) Median WBC = 9.8 (range 7.5-13.3) -Neutrophilia (>70%) 7/10 -Band forms (>5%) 4/5 Elevated transaminase level 9 /10 Hypoxia 6/10

6. Initial Radiologic Findings in Patients with Inhalational Anthrax (n=10) CXR abnormal in all 10 -mediastinal widening = 7 -infiltrates = 7 -pleural effusion = 8 CXR abnormalities can occur within 48 hours of onset of symptoms

7. Inhalational Anthrax CXR Case 1 Jernigan JA, EID 2001; 7: 933-44

8. Inhalational Anthrax CXR Case 7 Jernigan JA, EID 2001; 7: 933-44

9. Inhalational Anthrax CT Case 7 Jernigan JA, EID 2001; 7: 933-44

10. Inhalational Anthrax CXR Case 2 Jernigan JA, EID 2001; 7: 933-44

11. Inhalational Anthrax CT Case 2 Jernigan JA, EID 2001; 7: 933-44

12. Diagnosis of Inhalational Anthrax Blood cultures grew B. anthracis in all pts without prior antibiotic treatment (n=7) Diagnosis established in 3 pts without + cultures - Immunohistochemical staining -B. anthracis DNA detected by PCR -Rise in anti-PA IgG

13. Clinical Course of Inhalational Anthrax Survival: 60%, higher than <15% previously reported Bacteremia: occurs early in course, before onset of fulminant phase WBC: initially normal or minimally elevated, rises during course (median peak WBC= 26,400; range 7.5-49.6) Pleural effusions: present in all cases; hemorrhagic, progressive; required drainage in 70%

14. Cutaneous Anthrax Incubation period 1 to 12 days Painless papule Papule progresses to Vesicle or bulla with surrounding edema Central vesicle becomes ulcerated and necrotic, often surrounded by satellite vesicles Subsequently forms a black eschar, depressed and painless Fatigue, fever/chills, regional lymphadenopathy may occur

15. Summary – Inhalational Anthrax Profound sweating & GI symptoms notable CXRs uniformly abnormal – variety of findings Blood cultures positive early in course, before antibiotics Pleural effusions important feature of illness, frequently require drainage Pulmonary infiltrates a dominant radiologic feature in some patients Survival higher than <15% previously reported

16. Summary – Cutaneous Anthrax Incubation period 1 to 12 days Painless papule vesicle or bulla; edema necrosis, black eschar Systemic infection with bacteremia may occur