1. ANTHRAX D. Goldberg, MD Ped ID Service WRAMC

2. Anthrax Etiology-Bacillus anthracis toxin producing gram positive encapsulated spore forming non motile rod

3. Anthrax

4. Anthrax zoonotic disease-spores found on skin/hides carcasses of goats, cattle, horses, buffalo, sheep. Spread thru contaminated meat, feed, soil agricultural disease-spores found in soil and remain viable for up to 40 years incubation period is 1-7 (2-5) days

5. Anthrax- Inhalation-18 cases/US 1900-1978 Cutaneous-2000 cases/yr 244 cases/US 1944-1994 Gastrointestinal-occasional outbreaks

6. Anthrax Sverdlovsk (1979)-79 cases /68 deaths due to accidental aerosolized release WHO (1970)-50 kg aersolized over rban population would lead to 100,000 deaths US Congress (1993)-100 kg lead to 130,000-3 million deaths

7. Anthrax Cinical- Three forms: Cutaneous Gastrointestinal- oropharyngeal/abdominal Inhalational

8. Anthrax-Cutaneous 95% of all American cases Requires a break in the skin Initial manifestation is itching--> papule- -> vesicle--> depressed painless black eschar

9. Anthrax-Cutaneous Eschar surrounded by secondary vesicles (1-3mm) and erythema Untreated case fatality 5-20% due to spread into lymph/bloodstream No data to suggest prolonged latency (>14 days)

10. Anthrax-Cutaneous

11. Anthrax-Gastrointestinal Due to ingestion of infected undercooked meat Presents with nausea, fever, bloody diarrhea, Often proceeds to toxemia, shock and death (fatality rate -50%)

12. Inhalation Anthrax-Pathogenesis Inhalation Anthrax-Pathogenesis Spore particles- 1-5  m Spores transported to mediastinal lymph nodes (germination may be delayed up to 60 days) Spores release toxins- hemorrhage, edema, necrosis

13. Anthrax-Inhalation Inhalation of 8000-50,000 spores Initial sx are of mild URI, malaise, fatigue Initial sx followed by short period of improvement (hrs-2 days)

14. Anthrax-Inhalation Day 3-5 beginning of increasing resp distress of fever, tachypnea, rales, cyanosis CXR-mediastinal widening +/- effussions are seen in late stage in 55% cases Pneumonia generally does not occur

15. Anthrax-Inhalation

16. Anthrax-Inhalation Associated with hemmorhagic menningitis in 50% cases Case fatality rate is 100% untreated. Treatment begun “late” is ineffective

17. Anthrax-Diagnosis Gram stain of nasal swab/ discharge/lesion Culture ELISA for toxin Fluorescent Ab PCR

18. Inhalation Anthrax-Therapy Treatment- Ciprofloxacin (400mg IV q12) switch to Pen or Doxy if sensitive for 60 days Prophylaxis- Ciprofloxacin (500mg po q12) switch to Pen or Doxy if sensitive for 28-60days

19. Inhalation Anthrax-Therapy Pediatric Guidelines Initial therapy-Cipro 10-15 mg/kg/dose q12 then switch pending sensitivity Prophylaxis-same

20. Inhalation Anthrax- Alternative Therapies Doxycycline 2.5 mg/kg (max=100) q 12 when Cipro is unavailable/advisableDoxycycline 2.5 mg/kg (max=100) q 12 when Cipro is unavailable/advisable Amoxicillin 12-15 mg/kg q8 <20 kgAmoxicillin 12-15 mg/kg q8 <20 kg 500 mg q8 >20 kg 500 mg q8 >20 kg after sensitivities are known after sensitivities are known

21. References: Anthrax as a Biological Weapon: Inglesby, Henderson, et al; JAMA 281,18 1735-46 (May 1999) Chemical-Biological Terrorism and It's Impact on Children: Pediatrics 105,3 662-70 (March 2000) Bluebook-USAMRIID web site-