Anthrax in adults and children: a review of 132 cases in Turkey

Impact of traditional cutaneous scarification on anthrax lesions: A series of cases from Cubal, Angola

OBJECTIVES

Bacillus anthracis infection is a worldwide zoonosis that affects the most vulnerable population and has a high mortality rate without treatment, especially in non-cutaneous presentations. Cutaneous scarification is still common in some regions of the world for the treatment of certain diseases as part of traditional medicine. We describe a series of cutaneus anthrax from a rural setting in Angola where cutaneus scarification is common.

CASE PRESENTATION

This is a retrospective observational study describing a series of cutaneous anthrax cases from Cubal (Angola), many of whom were treated with skin scarification before admission. A total of 26 cases were diagnosed from January 2010 to December 2018. None of the cases were confirmed and eight (30.8%) were probable cases according to the Centers for the Disease Control and Prevention anthrax case definition. The median age was 11 (4.7-30.5) years, 17 (65.4%) had lesions on the head, face, or neck and 15 (57.7%) were treated with cutaneous scarification. Nine (34.6%) patients died. Traditional cutaneous scarification was significantly associated with cutaneous superinfection, respiratory, systemic involvement, and death.

CONCLUSION

Our case series points to increased complications and worse outcome of cutaneous anthrax disease if treated with skin scarification.

Risk Factors for Death or Meningitis in Adults Hospitalized for Cutaneous Anthrax, 1950-2018: A Systematic Review

BACKGROUND

Cutaneous anthrax accounts for approximately 95% of anthrax cases worldwide. About 24% of untreated patients die, and many cases are complicated by meningitis. Here, we explore clinical features of cutaneous disease associated with poor outcomes.

METHODS

A systematic review identified 303 full-text articles published from 1950 through 2018 that met predefined inclusion criteria. Cases were abstracted, and descriptive analyses and univariate logistic regression were conducted to identify prognostic indicators for cutaneous anthrax.

RESULTS

Of 182 included patients, 47 (25.8%) died. Previously reported independent predictors for death or meningitis that we confirmed included fever or chills; nausea or vomiting; headache; severe headache; nonheadache, nonmeningeal signs; leukocytosis; and bacteremia. Newly identified predictors included anxiety, abdominal pain, diastolic hypotension, skin trauma, thoracic edema, malignant pustule edema, lymphadenopathy, and evidence of coagulopathy (all with P < .05).

CONCLUSIONS

We identified patient presentations not previously associated with poor outcomes.

Human Cutaneous Anthrax, the East Anatolian Region of Turkey 2008-2014

Anthrax is a zoonotic infectious disease caused by Bacillus anthracis. While anthrax is rare in developed countries, it is endemic in Turkey. The names of the different forms of the disease refer to the manner of entry of the spores into the body-cutaneous, gastrointestinal, inhalation, and injection. The purpose of this study was to evaluate the clinical characteristics, epidemiological history, treatment, and outcomes of patients with anthrax. Eighty-two cases of anthrax hospitalized at Atatürk University Faculty of Medicine Department of Infectious Diseases and Clinical Microbiology in 2008-2014 were examined retrospectively. Gender, age, occupation, year, history, clinical characteristics, character of lesions, length of hospitalization, and outcomes were recorded. Thirty (36.6%) patients were female and 52 (63.4%) patients were male; ages were 18-69 and mean age was 43.77 ± 13.05. The mean incubation period was 4.79 ± 3.76 days. Cases were largely identified in August (41.5%) and September (25.6%). Sixty-nine (84.1%) of the 82 patients had been given antibiotics before presentation. Lesions were most common on the fingers and arms. The most common occupational groups were housewives (36.6%) and people working in animal husbandry (31.7%). All patients had histories of contact with diseased animals and animal products. Penicillin-group antibiotics (78%) were most commonly used in treatment. One patient (1.2%) died from anthrax meningitis. The mean length of hospitalization was 8.30 ± 5.36 days. Anthrax is an endemic disease of economic and social significance for the region. Effective public health control measures, risk group education, vaccination of animals, and decontamination procedures will reduce the number of cases.

Cutaneous anthrax: evaluation of 28 cases in the Eastern Anatolian region of Turkey

CONTEXT

Anthrax is an endemic disease in developing countries. Human cases are usually associated with animal products. About 95% of naturally acquired cases are cutaneous anthrax.

OBJECTIVE

In this study, cutaneous anthrax cases from the Elazig province (the Eastern Anatolian region) of Turkey seen in our hospital within a 6-year period were evaluated with respect to epidemiological and clinical features, diagnosis, treatment and outcome.

METHODS

Twenty-eight patients with cutaneous anthrax observed between January 2009 and December 2014 were investigated retrospectively. The diagnosis of cutaneous anthrax was based on detailed history, dermatologic findings, including painless, ulcers covered by a characteristic black eschar and/or microbiological procedures, including Gram stain and culture of materials obtained from the lesions.

RESULTS

Of the 28 patients followed up with cutaneous anthrax diagnosis, 14 (50%) were female and 14 (50%) were male. The mean age of the cases was 39.6 years (age range 17-65 years). The patients have an incubation period in the range of 1-9 days (mean 4.6 ± 0.5 days). The cases were seen between April and November of each year during the study period. Twenty-three cases (82%) had a history of contact with animals or animal products. Twenty patients (71.4%) showed malignant pustules and eight (28.6%) malignant edema. Bacillus anthracis was isolated in three cases (10.7%) and Gram stain smear were positive in five cases (17.8%). All patients were treated successfully with penicillin or ciprofloxacin. Systemic corticosteroids were added to the antibiotic treatment in six patients with malignant edema. Sepsis no developed in patients, all the cases recovered.

CONCLUSION

Anthrax is still a serious public health problem in Turkey. Cutaneous anthrax must always be kept in mind when characteristic lesions such as a painless ulcer with vesicles, edema, and a history of contact with animals or animal products are observed in an individual. Early and correct diagnosis significantly affects course of the disease. Protective precautions such as vaccination of animals against anthrax and education of the population would reduce the incidence of the disease.

Awareness and attitude toward zoonoses with particular reference to anthrax among cattle owners in selected rural communities of Zimbabwe

We conducted a cross-sectional study to assess cattle owners' awareness, perceptions, and attitudes toward zoonoses, with particular emphasis regarding anthrax. Data on awareness of zoonoses, clinical signs of anthrax in animals and human, its routes of transmission and methods of prevention, the families' consumption habits of anthrax-infected carcasses, and other family activities that increase exposure to anthrax were collected using an interviewer-administered questionnaire. A total of 41.4% (135/326) of the farmers were from high-anthrax-risk districts, whereas 28.5% and 30.1% were from medium- and low-risk districts, respectively. Overall, the level of awareness amongst the farmers for the named zoonoses were rabies (88.7%), anthrax (71.5%), and brucellosis (20.9%). Except for anthrax, awareness of other zoonoses did not differ significantly (p>0.05) among the district categories. Farmers from anthrax high-risk districts were significantly more aware of anthrax compared to those from moderate- (p=0.000) and low- (p=0.000) risk districts. All of the farmers were aware that anthrax occurs in cattle, and 73% indicated the presence of unclotting blood oozing from natural orifices as a consistent finding in cattle that died of anthrax, whereas 86.7% of them indicated the presence of skin lesions as the most common sign of the disease in humans. The good efficacy of human anthrax treatment (58.3%), slaughter of moribund cattle and selling of meat from cattle found dead to unsuspecting consumers (59.8%), reluctance to lose animals (47.9%), and forgetting about anthrax (41.1%) were cited as the major reasons for consuming anthrax-infected carcasses. Given that 75.2% of cattle owners indicated that they would not consume meat from cattle found dead, because they were discouraged by veterinary authorities, introducing meat inspection services is likely to have a positive impact in preventing human anthrax outbreaks in Zimbabwe.

Molecular epidemiology of the Bacillus anthracis isolates collected throughout Turkey from 1983 to 2011

The main perspective of this study was to determine cross-transmissions amongst anthrax cases and provide detailed information regarding the genotypes of Bacillus anthracis isolates circulating in Turkey. A total of 251 B. anthracis isolates were obtained from human (93 isolates), animal (155 isolates), and environmental (three isolates) samples in various provinces of Turkey. All isolates were susceptible to quinolones, vancomycin, tigecycline, and linezolid, but not to ceftriaxone. Excluding human isolates, one of the animal isolates was found to be resistant to penicillin, erythromycin, and doxycycline. Multiple-locus variable-number tandem repeats analysis including 8 loci (MLVA8) revealed 12 genotypes, in which genotype 43 was observed at the highest frequency (41.8 %), followed by genotype 35 (25.5 %) and genotype 27 (10.4 %). Major subtype A3.a was the predominant cluster, including 86.8 % of the isolates. The MLVA25 analysis for the 251 isolates yielded 62 different genotypes, 33 of which had only one isolate, while the remaining 29 genotypes had 2 to 43 isolates, with a total of 218 isolates (86.9 %). These findings indicate very high cross-transmission rates within anthrax cases in Turkey. The genotypes diagnosed in Turkey are populated in the A major cluster. Penicillin prescribed as the first-choice antibiotic for the treatment of anthrax is still effective.

Phase 1 study of a recombinant mutant protective antigen of Bacillus anthracis

A phase 1 study of a recombinant mutant protective antigen (rPA) vaccine was conducted in 186 healthy adults aged 18 to 45 years. Volunteers were randomized to receive one of three formulations of rPA (formalin treated, alum adsorbed, or both), in 10- or 20-μg dosages each, or the licensed vaccine, AVA. Three injections were given at 2-month intervals and a 4th 1 year after the 3rd. Vaccinees were examined at the clinic once following each injection, at 48 to 72 h postinjection. Adverse reactions were recorded in diaries for 7 days. Sera were collected before each injection and 1 week after the 1st, 2 weeks after the 3rd and 4th, and 1 year after the 4th. Serum anti-PA IgG was assayed by enzyme-linked immunosorbent assay (ELISA) and toxin neutralization assay (TNA). All formulations at both dosages were safe and immunogenic, inducing booster responses, with the highest antibody levels following the 4th injection (354 to 732 μg/ml). The lowest levels were induced by the formalin-only-treated rPA; there was no statistical difference between levels induced by alum-adsorbed and formalin-treated/alum-adsorbed rPA or by the two dosages. The antibody levels declined in all groups during the 1-year intervals after the 3rd and 4th injections but less so during the 2nd year, after the 4th injection (fold decreases were 10 to 25 versus 3.4 to 7.0, P < 0.001). There were too few AVA recipients for statistical comparisons, but their antibody levels followed those of rPA. Anti-rPA measured by ELISA correlated with TNA titers (r = 0.97). These data support studying alum-adsorbed rPA in children.

A review of cutaneous anthrax and its outcome

Anthrax is still an endemic disease in some countries in the world and has become a re-emerging disease in western countries with recent intentional outbreak. The aim of this study was to review our clinical experience with cutaneous anthrax cases. From the patient's files, transmission of the diseases, clinical findings and severity of infection, treatment and outcome of patients were recorded. Twenty-two cases were diagnosed as cutaneous anthrax in the last 7 years. Of these cases, 10 cases were severe form of cutaneous anthrax, 10 cases were mild form and 2 cases were toxemic shock due to cutaneous anthrax. The incubation period was between 1 and 17 days. The main clinical characteristics of the cases with severe cutaneous anthrax were fever, hemorrhagic bullous lesions surrounded by an extensive erythema and edema, and leukocytosis. Two cases with toxemic shock had low systolic blood pressure, apathy and toxemic appearance, leukocytosis, hypoalbuminemia & hyponatremia. Penicillin G was given in 15 cases, amoxicillin in 4 and other antibiotics in 3 cases for 3-10 days. Skin lesion left deep tissue scar in 4 cases and were grafted. Physicians working in endemic areas and also in western countries should be aware of all clinical forms of anthrax.

Human anthrax in Turkey from 1990 to 2007

Anthrax is an endemic disease in Turkey, among other countries of the world. The potential of Bacillus anthracis as a bioterrorism agent makes anthrax an important global issue. The aim of the present study was to review human anthrax in Turkey during the last decade. Human anthrax cases recorded from 1990 to 2005 were obtained from the website of the Turkish Ministry of Health, and those recorded between 1995 and 2005 were plotted on a map of Turkey. Papers on anthrax published from Turkey between 1990 and 2007 were collected and reviewed. Most cases were recorded from the central and eastern parts of Turkey. Three of the reports appeared in international journals prior to 1990, 10 reports appeared in the 1990s, and 24 reports appeared after the anthrax events of 2001 in the United States of America. These reports included 926 cases, 426 of which could be reviewed: 413 (96.9%) cases of cutaneous anthrax, 8 (1.9%) cases of gastrointestinal anthrax, and 5 (1.2%) cases of anthrax meningitis. Of all the affected patients, 95.2% had contact with contaminated materials. All human origin isolates were sensitive to penicillin and did not produce beta-lactamase. Most of the patients (88.7%) had received penicillin G. Total mortality was 2.8%. Anthrax is an endemic disease in Turkey, and acquisition of infection is generally through contact with ill or dying animals or animal products. Sheep and cattle are generally involved. Most clinical disease in humans is cutaneous anthrax, although other clinical forms are seen and have a greater mortality. Penicillin remains the drug of choice in treating the disease. Controlling anthrax in humans depends on controlling the infection in animals.

Bacterial Infections

In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.

Cutaneous anthrax involving the genital area

A 5-year-old girl was admitted with a lesion of the labia majora which was found to be owing to anthrax. She had been licked on the hand by a sick cow (which subsequently died) 5 days prior to admission to a health clinic and 8 days before admission to hospital.

The seminal literature of anthrax research

A chronically weak area in research papers, reports, and reviews is the complete identification of seminal background documents that formed the building blocks for these papers. A method for systematically determining these seminal references is presented. Citation-Assisted Background (CAB) is based on the assumption that seminal documents tend to be highly cited. Application of CAB to the field of Anthrax research is presented. While CAB is a highly systematic approach for identifying seminal references, it is not a substitute for the judgment of the researchers, and serves as a supplement.

Bioterrorism-Related Inhalational Anthrax: Can Extrapolated Adult Guidelines Be Applied to A Pediatric Population?

OBJECTIVE

Since the 2001 anthrax attacks, an extensive body of literature has evolved, but there has been a limited focus on the management of pediatric-specific issues. We looked at the symptom complexes of all pediatric patients presenting to the emergency department of our hospital during this period and examined whether their presentations would likely allow current guidelines to be used as potential screening criteria to identify children infected with anthrax.

METHODS

We retrospectively reviewed emergency department records of all adult and pediatric patients (up to the age of 21 years) at Inova Fairfax Hospital during this time, when a large, and at the time ill-defined, group in the Washington, DC, metropolitan area was at risk for pulmonary anthrax. Two cases of anthrax infection were identified at this hospital in exposed adult postal workers. Screening algorithms (described by Mayer et al. and Hupert et al.) were applied to adult and pediatric patients with the presence of fever (38 degrees C), tachycardia, or other symptoms compatible with pulmonary anthrax. Specifically, the usefulness of these guidelines as potential screening tools to identify possibly infected children was examined.

RESULTS

Of 767 pediatric patients seen in the emergency department during the study period, 312 met criteria for review (41%; 95% CI: 37-44%). Four adult patients (0.4%; 95% CI: 0.1-0.9%) had at least five clinical symptoms, fever, and tachycardia; two of them had inhalational anthrax. No pediatric patient presented with five or more clinical symptoms. Twelve children (3.9%; 95% CI: 2-6.6%) presented with four clinical symptoms; five of the 12 had neither fever nor tachycardia. Children, particularly infants and toddlers, presented with nonspecific symptom complexes primarily limited to fever, vomiting, cough, and trouble breathing.

CONCLUSIONS

Existing guidelines are likely to be unreliable as a screening tool for inhalational anthrax in children, largely because of the children's inability to adequately communicate a suggestive symptom complex.

Additional conjugation methods and immunogenicity of Bacillus anthracis poly-gamma-D-glutamic acid-protein conjugates

The capsule of Bacillus anthracis, composed of poly-gamma-d-glutamic acid (gammaDPGA), is an essential virulence factor of B. anthracis. The capsule inhibits innate host defense through its antiphagocytic action. gammaDPGA is a poor immunogen, but when covalently bound to a carrier protein, it elicits serum antibodies. To identify the optimal construct for clinical use, synthetic gammaDPGAs of different lengths were bound to carrier proteins at different densities. The advantages of the synthetic over the natural polypeptide are the homogeneous chain length and end groups, allowing conjugates to be accurately characterized and standardized and their chemical compositions to be related to their immunogenicities. In the present study, we evaluated, in addition to methods reported by us, hydrazone, oxime, and thioether linkages between gammaDPGA and several proteins, including bovine serum albumin, recombinant Pseudomonas aeruginosa exotoxin A, recombinant B. anthracis protective antigen (rPA), and tetanus toxoid (TT). The effects of the dosage and formulation on the immunogenicities of the conjugates were evaluated in mice. All conjugates were immunogenic. The optimal gammaDPGA chain length of 10 to 15 amino acids and the density, an average of 15 mol gammaDPGA per mol of protein, were confirmed. The thioether bond was the optimal linkage type, and TT and rPA were the best carriers. The optimal dosage was 1.2 to 2.5 microg of gammaDPGA per mouse, and adsorption of the conjugates onto aluminum hydroxide significantly increased the antibody response to the protein with a lesser effect on anti-gammaDPGA levels.

Anthrax in eastern Turkey, 1992-2004

We investigated animal and human anthrax cases during a 13-year period in eastern Turkey. From 1992 to 2004, a total of 464 animal and 503 human anthrax cases were detected. Most cases occurred in summer. Anthrax remains a health problem in eastern Turkey, and preventive measures should be taken.