Inhalation Anthrax Case in Pennsylvania

On February 16, 2006, a 44-year-old man presented to a hospital in Pennsylvania with respiratory symptoms including dry cough, shortness of breath, and general malaise. Laboratory Response Network (LRN) and Polymerase Chain Reaction (PCR) on 2/21 and gamma phage lysis on 2/22 from blood culture isolate were positive for Bacillus anthracis.

Patient resides in New York City and makes drums from unprocessed domestic and imported (Africa) animal hides (cow and goat). Patient reports frequent travel to Africa (most recent travel 12/4/05–12/21/05). Patient reports last working with animal hides on 2/15. Process includes cleaning and removal of hair from hides without chemical fixatives. While traveling to Pennsylvania on 2/16, the patient collapsed with rigors and was transported and admitted to a small local hospital.

Patient transferred to a tertiary care center on 2/18. Patient is reported to be stable on antibiotic therapy in the ICU without mechanical ventilation. Patient has no signs of cutaneous or pharyngeal anthrax lesions. Preliminary clinical impression suggests anthrax sepsis secondary to inhalation route of exposure due to spores from contaminated animal hides.

Ongoing investigation by PA and NYC departments of health in coordination with law enforcement includes environmental assessment of patient's storage/work facility and home and identification of individuals who may have had contact with unprocessed hides.

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INFECTIOUS DISEASE	BACTERIOLOGY	IMMUNOLOGY	MYCOLOGY	PARASITOLOGY	VIROLOGY
	Inhalation Anthrax Case in Pennsylvania
This female patient is shown here on the 5th day of a Bacillus anthracis infection involving her left eye. Anthrax infections can occur in three forms: cutaneous (skin), inhalation, and gastrointestinal. Humans can become infected with anthrax by handling products from infected animals or by inhaling anthrax spores from contaminated animal products. CDC	On February 16, 2006, a 44-year-old man presented to a hospital in Pennsylvania with respiratory symptoms including dry cough, shortness of breath, and general malaise. Laboratory Response Network (LRN) and Polymerase Chain Reaction (PCR) on 2/21 and gamma phage lysis on 2/22 from blood culture isolate were positive for Bacillus anthracis. Patient resides in New York City and makes drums from unprocessed domestic and imported (Africa) animal hides (cow and goat). Patient reports frequent travel to Africa (most recent travel 12/4/05–12/21/05). Patient reports last working with animal hides on 2/15. Process includes cleaning and removal of hair from hides without chemical fixatives. While traveling to Pennsylvania on 2/16, the patient collapsed with rigors and was transported and admitted to a small local hospital. Patient transferred to a tertiary care center on 2/18. Patient is reported to be stable on antibiotic therapy in the ICU without mechanical ventilation. Patient has no signs of cutaneous or pharyngeal anthrax lesions. Preliminary clinical impression suggests anthrax sepsis secondary to inhalation route of exposure due to spores from contaminated animal hides. Ongoing investigation by PA and NYC departments of health in coordination with law enforcement includes environmental assessment of patient's storage/work facility and home and identification of individuals who may have had contact with unprocessed hides.
Anthrax lesion on the skin of the forearm caused by the bacterium Bacillus anthracis. Here the disease has manifested itself as a cutaneous ulceration, which has begun to turn black, hence the origin of the name "Anthrax", after the Greek name for coal. CDC Chest radiograph showing widened mediastinum due to inhalation anthrax. Radiograph taken 22 hours before death; AP Chest X-ray. CDC/Dr. P.S. Brachman	Update: Inhalation Anthrax Case Investigation, Pennsylvania, New York City – Update, 2/24/2006 Laboratory testing from the patient’s storage/work facility, his van and his residence have identified Bacillus anthracis. These findings are consistent with the hypothesis that the patient’s exposure occurred while working on contaminated hides while making traditional drums. The patient remains hospitalized in Pennsylvania. Investigation of other potentially exposed persons continues; seven persons are currently on post-exposure prophylaxis for inhalation anthrax. None of these individuals have symptoms of anthrax. In addition, surveillance has not identified any other illness consistent with anthrax disease in NY and PA. Animal hides pose a low risk of cutaneous anthrax, and an extremely low risk of inhalation anthrax. Exotic animal hides may pose a higher risk for exposure than domestic (U.S.-origin) hides. The risk of contracting Bacillus anthracis from handling individual hides is believed to be very low. The industrial handling of large numbers of hides, or hair from multiple animals, has historically been associated with increased risk of anthrax. Among the 236 cases of anthrax reported to CDC from 1955 to 1999, 153 (65%) were associated with industrial handling of animal hide or hair. Only 9 of the 153 cases (6%) associated with industrial handling of hair or hide were inhalation anthrax. The risk of acquiring anthrax from an animal hide drum is very low. Of 236 cases of anthrax reported to CDC from 1955 through 1999, only one case of cutaneous anthrax was associated with a goat hide bongo drum purchased in Haiti. No cases of inhalation anthrax in the US have ever been associated with animal hide drums. The New York patient’s exposure occurred when he was making and finishing drums made from untanned animal hides, and was not associated with playing finished drums. His exposure was similar to that experienced during industrial handling of hides, which has been previously associated with an increased risk of anthrax. CDC does not currently recommend prophylaxis for persons who have had contact with animal hide drums. However, drum owners or players should report any unexplained febrile illness or unusual skin lesions to their healthcare provider, and describe their recent contact with animal hide drums.
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