History

Fact Explanation
Fever [1] Bacteremia and systemic inflammatory response
Generalized body aches [1] Bacteremia and systemic inflammatory response
Rash Cutaneous Anthrax [1], [2], [3]. Initially occurs as a painless vesicle that gradually becomes a painless Black Eshcar [1], [2] If pain develops it is often due to secondary bacterial infection [3]
Cough - often non productive [2] Inhalational Anthrax [1]
Chest pain - Retrosternal [1] Mediastinal / Lung parenchyma inflammation following Inhalational Anthrax [1]
Shortness of breath Mediastinal / Lung parenchyma inflammation [1], Pleural effusion [2] following Inhalational Anthrax
Loose stools [2] Bloody diarrhea can occur [2] Due to Gastrointestinal Anthrax [2]
Haematemesis [2] Due to Gastrointestinal Anthrax [2]
Abdominal pain [3] Due to Gastrointestinal Anthrax [2]
Headache with associated photophobia, nausea, vomiting [3] Due to Anthrax Meningitis [3]
References
  1. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principle's of Internal Medicine. 18th Edition. 2012. McGrawHill-Medical. New York.
  2. KUMAR P, CLARK M. Kumar and Clark's Clinical Medicine. 8th Edition. 2012. Saunders-Elsevier. Edinburgh.
  3. DIXON TC, MESELSON M, GUILLEMIN J, HANNA PC. Anthrax. The New England Journal of Medicine. 1999; 341:815-826 September 9, 1999 DOI: 10.1056/NEJM199909093411107

Examination

Fact Explanation
Pyrexia [1] Systemic inflammatory response to infection
Rash - Papule/ Maculopapular/ Vesicular/ Eshcar [1] Due to Cutaneous Anthrax [2] Initially begins as a painless Papule that gradually becomes vesicular and turns into black painless eshcar [2]
Lymphadenopathy [3] Regional lymph node enlargement due to cutaneous anthrax, Generalized in case of Inhalational anthrax [3]
Respiratory signs - Signs of Pneumonia/ Signs of Pleural effusion [2] Due to inhalational Anthrax [2]
Signs of Meningism [2] Due to Anthrax Meningitis [2]
References
  1. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principle's of Internal Medicine. 18th Edition. 2012. McGrawHill-Medical. New York.
  2. DIXON TC, MESELSON M, GUILLEMIN J, HANNA PC. Anthrax. The New England Journal of Medicine. 1999; 341:815-826 September 9, 1999 DOI: 10.1056/NEJM199909093411107
  3. KUMAR P, CLARK M. Kumar and Clark's Clinical Medicine. 8th Edition. 2012. Saunders-Elsevier. Edinburgh.

Differential Diagnoses

Fact Explanation
Plague [1] Differential of Cutaneous Anthrax, Extreme tender lymph nodes (Buboes) found in Plague [2]
Cutaneous tuberculosis [1] Differential of Cutaneous Anthrax, Mantoux test would be positive, skip biopsy may demonstrate granuloma formation [3]
Ricckettsial pox [1] Differential of Cutaneous Anthrax, Almost identical skin manifestations, differentiated by investigations serology [4]
Typhoid [1] Differential of Gastrointestinal Anthrax. Bradycardia, Rosh spot's rash on trunk, Culture of Salmonella [5]
Peptic ulcer [1] Differential of Gastrointestinal Anthrax, Diagnosis of Helicobacter pylori, history of NSAID use [6]
Acute Bacterial mediastinitis [1] Differential for Inhalational Anthrax, 1) clinically evident oropharyngeal infection; 2) typical radiological findings of mediastinitis; 3) evident necrotizing mediastinal infection at surgery or postmortem examination or both; and 4) an evident relationship between oropharyngeal or cervical infection and necrotizing mediastinal process. [7]
Pneumonia due to Mycoplasma, Legionella [1] Differential of Inhalational Anthrax, Can be differentiated by Chest Xray findings or serology [4]
References
  1. DIXON TC, MESELSON M, GUILLEMIN J, HANNA PC. Anthrax. The New England Journal of Medicine. 1999; 341:815-826 September 9, 1999 DOI: 10.1056/NEJM199909093411107
  2. PERRY RD, FETHERSTON JD. Yersinia pestis--etiologic agent of plague. Clinical Microbiology Reviews 1997, 10(1):35.
  3. THAKUR KT, VERMA S, HAZARIKA D. A Clinicopathological Study of Cutaneous Tuberculosis at Dibrugarh District, Assam. Indian Journal of Dermatology. 2012 Jan - Feb: 57 (1): 63 - 65
  4. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principle's of Internal Medicine. 18th Edition. 2012. McGrawHill-Medical. New York.
  5. MASKALYK J. Typhoid fever. Canadian Medical Association Journal July 22, 2003 vol. 169 no. 2 132
  6. KUMAR P, CLARK M. Kumar and Clark's Clinical Medicine. 8th Edition. 2012. Saunders-Elsevier. Edinburgh.
  7. ESTRERA AS, LANDAY MJ, GRISHAM JM, SINN DP, PLATT MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983; 157: 545–52.

Investigations - for Diagnosis

Fact Explanation
Culture - Blood, sputum, Ascitic fluid, Meningeal fluid [1] Nonhemolytic and are white to gray, often looking like ground glass on blood agar [1]
Gram stain [1] Gram positive rods [1]
References
  1. DIXON TC, MESELSON M, GUILLEMIN J, HANNA PC. Anthrax. The New England Journal of Medicine. 1999; 341:815-826 September 9, 1999 DOI: 10.1056/NEJM199909093411107

Investigations - Fitness for Management

Fact Explanation
Chest Xray [1] To diagnose mediastinal widening due to risk of cardiovascular collapse [1], To diagnose Pleural effusions [1]
Chest CT [1] To diagnose mediastinal widening due to risk of cardiovascular collapse [1], To diagnose Pleural effusions [1]
References
  1. DIXON TC, MESELSON M, GUILLEMIN J, HANNA PC. Anthrax. The New England Journal of Medicine. 1999; 341:815-826 September 9, 1999 DOI: 10.1056/NEJM199909093411107

Investigations - Followup

Fact Explanation
Chest Xray [1] To monitor inhalational anthrax - Mediastinal widening, hemorrhagic pleural effusions [1]
Chest CT [1] To monitor inhalational anthrax - Mediastinal widening, hemorrhagic pleural effusions [1]
References
  1. EARLS JP, CERVA D, BERMAN E, et al. Inhalational Anthrax after Bioterrorism Exposure: Spectrum of Imaging Findings in Two Surviving Patients. The Journal of the American Medical Association 2001; 286:2549–2553

Investigations - Screening/Staging

Fact Explanation
Elevated White cell count - 10,000 cells/ micro liter [1] Due to Bacteraemia
Elevated Liver Enzymes [1] - Tranaminases Anthrax septicemia causes liver dysfunction [2]
References
  1. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principle's of Internal Medicine. 18th Edition. 2012. McGrawHill-Medical. New York.
  2. PIRIS-GIMENZA A, CORRE JP, JOUVION G, et al. Encapsulated Bacillus anthracis Interacts Closely with Liver Endothelium. Journal of Infectious Disease. (2009) 200 (9): 1381-1389. doi: 10.1086/644506

Management - General Measures

Fact Explanation
Mechanical ventilation [1] Due to severe pulmonary involvement or sepsis due to Inhalational Anthrax [1]
Vasopressor administration [1] For haemodynamic support due to septic shock [1]
References
  1. WARREL DA, COX TM, FIRTH JD. Oxford textbook of Medicine. 5th edition. 2010. Oxfo

Management - Specific Treatments

Fact Explanation
Penicillin V [1] Sensitive to Anthrax bacilli [2]. Dose of 8 million - 12 million units Intravenously per day in divided doses [1], [2]
Ciprofloxacin [1] Sensitive to Anthrax bacilli [2]. Dose of 200mg - 400mg Intra venously twice daily [1], [2]
Tetracycline [1] Sensitive to Anthrax bacilli [2]. Dose of 250mg - 500mg orally or intra venously every 4 hourly [1], [2]
References
  1. DIXON TC, MESELSON M, GUILLEMIN J, HANNA PC. Anthrax. The New England Journal of Medicine. 1999; 341:815-826 September 9, 1999 DOI: 10.1056/NEJM199909093411107
  2. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principle's of Internal Medicine. 18th Edition. 2012. McGrawHill-Medical. New York.