Anthrax

• Anthrax = coal
• Eschar in cutaneous anthrax
• Wild & domestic animals
• Humans rarely infected
• Occupational exposure: cutaneous anthrax
• Amongst drug users
• An agent of bioterrorism
The Organism
Genus Bacillus

• Aerobic bacilli
• Forms heat-resistant spores
• Gram +ve, tend to decolorize easily
• Generally motile, peritrichate flagella
 Genus Bacillus
• Exhibit great diversity – psychrophilic, mesophilic & thermophilic species
• Spores – ubiquitous – commonest lab contaminants
Genus Bacillus

• B. anthracis – major pathogen

• B. cereus – food-borne gastroenteritis
– opportunistic infections
• B. subtilis – opportunistic infections
 The Organism
• Bacillus anthracis
• Large, Gram +ve non-motile rod
• Vegetative form & spores
• Nearly worldwide distribution
• Over 1,200 strains
 The Organism
• 3-10 µm x 1-1.6 µm
• In tissues: singly, in pairs & short chains
• Capsule: not formed in culture
The Spore

• Sporulation requires
• Poor nutrient conditions
• Presence of oxygen
• Spores
• Very resistant to extremes
• Survive for decades
• Taken up by host & germinate
• LD: 2,500 - 55,000 spores
Virulence factors

• Capsule
• Toxins:
• Protective Ag
• Lethal Factor
• Edema Factor
• Plasmids:
• pX01 (184.5 kbp) – contains toxin genes
• pX02 (95.3 kbp) – encodes capsule
Bacillus anthracis
 Historically . . .
• 1st:
• Pathogen observed microscopically (Pollander, 1849)
• Communicable disease shown to be transmitted by inoculation of infected blood
(Davaine, 1850)
• Bacillus to be isolated in pure culture & shown to possess spores (Koch, 1876)
• Bacterium used for preparation of an attenuated vaccine (Pasteur, 1881)
Medieval illustration depicts the plague on Egyptian cattle
Anthrax

• Anthrakitis (Greek): coal

• Likely originated 6,000-7,000 yr ago in Mesopotamia & Egypt
As a Bioweapon

• Unit 731 of Japanese Army

• In Manchuria
• 1930s
• Intentional infection of PoW
• Thousands died
2001 Anthrax Letters
Anthrax Cases, 2001

• 22 cases
• 11 cutaneous
• 11 inhalation
• 5 deaths (all inhalation)
• Index case in Florida
• 2 postal workers in Maryland
• Hospital supply worker in NYC
• Elderly farm woman in Connecticut
 Anthrax Cases, 2001

• 7 month old boy

• Visited ABC Newsroom
• Cutaneous lesion
• Initial diagnosis:
• spider bite
• Punch biopsies confirmed anthrax
Anthrax Cases, 2001

• Antimicrobial prophylaxis
• Ciprofloxacin
• 5,342 prescribed
• 60 day regime
• 44% compliance
• 57% suffered side effects
Epidemiology in 21st Century

• Agricultural: farm workers

• Non-industrial:
• Laboratorians
• Civilians
• Industrial: processors of animal products
• Intentional: inhalational / cutaneous
Current Issues

• Endemic public health threat

• One of the most important bioterrorism agents
• Aerosolized stable spore form
• Human LD50 :
˷10,000 spores (one deep breath at site of release)
Anthrax BT Issues
Clinical Information
Synonyms

• Malignant Pustule
• Malignant Edema
• Woolsorters’ Disease
• Ragpickers’ Disease
• Maladi Charbon
• Splenic Fever
Pathogenesis

• Virulence factors:
• Capsule
• Toxins:
• Edema factor (EF)
• Lethal factor (LF)
• Protective antigen (PA)
Capsule

• Under anaerobic conditions

• Polypeptide – poly-D-glutamic acid
• Synthesis by three enzymes encoded by capA, capB & capC genes on
pX-02 plasmid
Toxins

• EF & LF bind PA – enters target cell

• Encoded on plasmid pX-01
• LF:
• Zn-dependent metallopeptidase
• Inhibits dendritic cell function
• EF:
• Converts AMP to cAMP
• Results in dysregulation of water & ions
Clinical Types

• Cutaneous anthrax
• GI anthrax
• Inhalational anthrax
• CNS disease
Cutaneous Anthrax

• >95% of cases
• Acquired by direct contact with infected animals / products
• IP: 1–12 d
• Initial pruritic papule – vesicular / bullous lesion
Cutaneous Anthrax

• Surrounded by extensive non-pitting oedema

• Central part: necrotic & haemorrhagic
• Satellite vesicles
• Finally – a classic black eschar – falls off in 1–2 wk
GI Anthrax

• <5% of cases
• Oropharyngeal anthrax:
• Fever & cervical adenopathy & soft tissue oedema
• Ingestion of contaminated meat
• Intestinal anthrax:
• Commoner
• Fever, syncope & malaise
• Abdominal pain, nausea & vomiting
GI Anthrax

• Intestinal anthrax:
• Abdominal distension
• Mass in right iliac fossa / periumbilical area
• Third phase: paroxysmal abdominal pain, ascites, facial flushing, red
conjunctivae & shock
Inhalational Anthrax

• Very rare
• Inhalation of spores
• IP: <1 wk
• Flu-like illness, nonproductive cough
• Haemorrhagic mediastinal lymphadenopathy
• Multilobar pneumonia ± pleural effusions
• Bacteraemia
Inhalational Anthrax

• CXR: widened mediastinum

• Mortality rate: 45-85%
CNS Disease

• Very rare
• Haemorrhagic meningoencephalitis
• 95% mortality
Cutaneous Anthrax
Cutaneous Anthrax

Papule

Vesicle

Eschar
Cutaneous Anthrax

• Edema, redness &/or necrosis without ulcer may occur

• Most commonly encountered natural form
• Incubation period: 1-12 d
• Case fatality:
• Without treatment: 20%
• With treatment: 1%
Inhalational Anthrax
Inhalational Anthrax

• Brief prodrome of ‘flu-like’ illness

• Hypoxia & dyspnoea
• CXR: mediastinal widening, pleural effusion
Inhalational Anthrax
Inhalation of spores

Alveolar spaces
Phagocytosis by macrophages
Mediastinal & peribronchial LNs
Germination
Active bacterial growth

Production & elaboration of toxins (PA, EF, LT)

Hematogenous spread
CV collapse & death
Inhalational Anthrax

• Meningitis in 50%
• Rare in natural outbreaks (20 cases in US: 20th century)
• Incubation period: 1-7 d (up to 42 d)
• Case fatality:
• Without treatment: 97%
• With treatment: 75%
 Gastrointestinal Anthrax
• Abdominal distress, vomiting, dysentery
• Followed by fever, signs of septicemia
• Oropharyngeal ulceration with cervical adenopathy
• Follows ingestion of contaminated undercooked meat
• Incubation period: 1-7 d
• Case fatality: 25-60% (role of early treatment – undefined)
Differential Diagnosis
Cutaneous Anthrax

• Spider bite
• Ecthyma gangrenosum
• Tularemia (ulceroglandular)
• Plague
• Staph / Strep cellulitis
• Herpes simplex
Inhalational Anthrax

• Mycoplasma pneumonia
• Legionnaires’ disease
• Psittacosis
• Tularemia
• Q fever
• Viral pneumonia
• Histoplasmosis
• Coccidioidomycosis
• Malignancy
GI Anthrax

• Acute appendicitis
• Ruptured viscus
• Diverticulitis
• Dysentery
Diagnosis
Cutaneous Anthrax

• Vesicular fluid, exudate, eschar:

• Gram stain
• PCR
• Culture
• Blood culture
• Bx for IHC
 Inhalational Anthrax
• CXR:
• Widened mediastinum
• Pleural effusion
• Infiltrates
• Congestion
• Tissue Bx - IHC
• Sterile site fluid - Gram stain, PCR, culture
• Pleural fluid cell block - IHC
GI Anthrax

• Blood culture
• Oropharyngeal swab
Gram Stain Morphology

• Broad Gram +ve rods: 3-10 µm x 1-1.6 µm

• Oval, central to subterminal spores: 1-1.5 µm with no swelling of cell
• Spores usually not present in clinical specimens unless exposed to O2
Gram stain of peripheral blood buffy coat
from a patient with inhalational anthrax

Gram stain of blood culture media from

a patient with inhalational anthrax
Colony Characteristics

• BA plates at 35-370 C x 12-24 h: well-isolated colonies 2-5 mm dia

• Gray-white, flat to slightly conves colonies, irregularly round with
slightly undulated edges, ground glass appearance
• Comma-shaped protrusions from colony edge (‘Medusa-head’)
‘Medusa head’
Colony Characteristics

• Tenacious consistency
• Nonhemolytic
• McConkey medium: no growth
• Nonmotile
Culture

• Sheep BA – non-capsulated broad rods in long chains

• Nutrient agar supplemented with 0.8% NaHCO3 in presence of 5%
CO2 – encapsulated bacilli
Prophylaxis
 Anthrax Vaccine Adsorbed
• Only FDA-approved anthrax vaccine
• 3 injections at 0, 2, 4 weeks followed by booster at 6, 12, & 18 months
• “Acceptably safe”
• Not available to public
Treatment
 Inhalation Anthrax Treatment Protocol

Category Initial Therapy (IV) Duration

Adults Ciprofloxacin 400 mg every 12 h IV treatment initially. Switch to oral
Or therapy when clinically appropriate:
Doxycycline 100 mg every 12 h Ciprofloxacin 500 mg PO BID
Or
Doxycycline 100 mg PO BID
Continue for 60 d
Children Ciprofloxacin 10-15 mg/kg every IV treatment initially. Switch to oral
12 h therapy when clinically appropriate:
Or Ciprofloxacin 10-15 mg/kg PO every
Doxycycline 12 h
> 8 yr & > 45 kg: 100 mg every Or
12 h Doxycycline: > 8 yr & > 45 kg:
> 8 yr & < 45 kg: 2.2 mg/kg 100 mg PO BID
every 12 h > 8 yr & < 45 kg: 2.2 mg/kg PO BID
< 8 yr: 2.2 mg every 12 h < 8 yr: 2.2 mg PO BID
and
1 or 2 additional antimicrobials
 Disinfection & Disposal
• Commercially-available bleach (0.5% hypochlorite)
• Accidental spills of contaminated material
• Gently cover spill, liberally apply sporicidal solution
• Soak for 30 minutes, clean
• Autoclave / incinerate any soiled material
• Cultures, infected materials, suspect materials – incinerate / steam
sterilize
 Disinfection & Disposal
• Oxidizing agents:
• Peroxides
• Ethylene oxide
• Chlorine dioxide
• Liquid bleach products
• One part bleach (6%) + one part white vinegar + eight parts water