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.     

Human anthrax in India: urgent need for effective prevention.

Anthrax is a zoonotic illness caused by Bacillus anthracis. Sporadic cases continue to be reported from many parts of the world. From India, both sporadic cases and outbreaks are being reported regularly. The Union Territory of Pondicherry (a former French colony) lies on the coast of Bay of Bengal, where the incidence of anthrax is on the rise with 28 cases being detected in the year 1999 and 2000 alone. So far, about 34 human cases have been encountered in this region. Recently, an increase in the number of anthrax cases has been noted in veterinary and human practice in this area. Most cases have occurred in agricultural labourers who gave history of handling animal meat or skin of infected animals. The meningitic form of the disease has a very bad prognosis. Patients with this form of disease died despite treatment with high dose penicillin. The typical bacilli were seen in the CSF in all cases of anthrax meningitis and was diagnostic of the condition. The cutaneous form of illness had a benign course and responded favourably to penicillin treatment. Awareness among clinicians and mandatory reporting of cases to public health departments along with public education will help control morbidity and mortality due to anthrax. Effective immunization of animals is the other important control measure for anthrax.     

A case of anthrax meningitis

Meningeal anthrax is a very rare complication of the cutaneous, respiratory and gastrointestinal form of anthrax infection. Anthrax bacilli, most commonly enter the body via the skin, and the organism then disseminates to the central nervous system via the hematogenous or lymphatic routes leading to fatal bacterial meningitis, even with intensive antibacterial therapy.     

An outbreak of human anthrax in Mysore (India)

Anthrax is a zoonotic disease caused by Bacillus anthracis. Intestinal anthrax though a rare entity mostly ends with fatal outcome. Very few cases of intestinal anthrax are reported. Present outbreak of intestinal anthrax is unique in itself that four cases succumbed to the illness within a span of 48-72 hours in a small hamlet of Mysore district of Karnataka, after consuming diseased deer meat. Confirmation of the diagnosis was carried out at NICD, Delhi by bacteriological culture isolation, biochemical tests, animal pathogenicity and polymerase chain reaction (PCR). This outbreak clearly indicates surveillance of anthrax in animals in endemic areas is an essential part in the control of the disease with intersectoral coordination between the departments of health, animal husbandary, agriculture and forest.     

Cutaneous anthrax in Turkey: a review of 32 cases

Anthrax, caused by the Gram-positive, rod-shaped, spore-forming bacterium Bacillus anthracis, is rarely seen in industrialized nations but is common in developing countries. Cutaneous anthrax accounts for 95% of cases and usually develops on exposed sites. This study reviews the clinical and laboratory findings of 32 patients diagnosed with cutaneous anthrax over a 4-y period in the eastern part of Turkey. All patients had a history of direct contact with infected animals. The patients, aged 6-72 y, comprised 17 (53%) males and 15 (47%) females. The most frequent localization site of skin lesions was the hands and fingers (31 patients), whereas the suborbital part of the face was invaded in 1 patient. The diagnosis was made as a result of typical clinical lesions, direct microscopy or bacterial isolation. All but 2 patients were successfully treated with penicillin; these other 2 patients were treated initially with sulbactam-ampicillin. All patients, including the patient with suborbital anthrax, were cured.     

Gastrointestinal adverse reactions following anthrax vaccination: an analysis of the Vaccine Adverse Events Reporting System (VAERS) database

BACKGROUND/AIMS: The Institute of Medicine (IOM) of the United States Academy of Sciences in 2000 encouraged the evaluation of active long-term monitoring studies of large populations to further evaluate the relative safety of anthrax vaccine. Anthrax is a deadly bacterial infectious disease that currently has been engineered as a biological warfare agent. The vaccine produced against anthrax is a cell-free crude culture of the various toxin components of the natural disease. The U.S. military current goal is to vaccinate its entire personnel by 2003. The purpose of this study was to evaluate anthrax vaccination and its association with arthritic, immunological and gastrointestinal adverse reactions based upon analysis of the Vaccine Adverse Events Reporting System (VAERS) database. METHODOLOGY: We analyzed the VAERS database from 15 December 1997 to 12 April 2000. We also compared the incidence of anthrax adverse reactions with the incidence of adverse reactions reported to VAERS after adult tetanus vaccination. RESULTS: Anthrax vaccine was one of the most reactogenic vaccines included in VAERS. The incidence of adverse reactions reported following anthrax vaccine was higher for every reaction analyzed in comparison to the adult vaccine control groups. CONCLUSIONS: The current anthrax vaccine may be acceptable in military populations in impending threat of anthrax exposure, the cost-benefits of vaccination in less high risk military populations may be more questionable. Civilian anthrax vaccination will require a less reactogenic vaccine. Civilian doctors should be aware of anthrax vaccine adverse reactions. Military and civilian doctors should also be diligent in their reporting to VAERS of cases of adverse reactions to anthrax vaccine.     

Inhalational anthrax: epidemiology, diagnosis, and management

Anthrax, a disease of great historical interest, is once again making headlines as an agent of biological warfare. Bacillus anthracis, a rod-shaped, spore-forming bacterium, primarily infects herbivores. Humans can acquire anthrax by agricultural or industrial exposure to infected animals or animal products. More recently, the potential for intentional release of anthrax spores in the environment has caused much concern. The common clinical manifestations of anthrax are cutaneous disease, pulmonary disease from inhalation of anthrax spores, and GI disease. The course of inhalational anthrax is dramatic, from the insidious onset of nonspecific influenza-like symptoms to severe dyspnea, hypotension, and hemorrhage within days of exposure. A rapid decline, culminating in septic shock, respiratory distress, and death within 24 h is not uncommon. The high mortality seen in inhalational anthrax is in part due to delays in diagnosis. Classic findings on the chest radiograph include widening of the mediastinum as well as pleural effusions. Pneumonia is less common; key pathologic manifestations include severe hemorrhagic mediastinitis, diffuse hemorrhagic lymphadenitis, and edema. Diagnosis requires a high index of suspicion. Treatment involves supportive care in an intensive care facility and high doses of penicillin. Resistance to third-generation cephalosporins has been noted. Vaccines are currently available and have been shown to be effective against aerosolized exposure in animal studies.     

Anthrax in children: a long forgotten, potentially fatal infection

After a brief account of anthrax morbidity in northern Greece in recent years, 4 cases in 1977 of cutaneous anthrax in 10 to 13-year-old children are presented. Two had an atypical cutaneous lesion. In 1 of these, a 13-year-old girl, the disease was complicated by severe, eventually fatal meningitis. Death ensued despite intensive treatment with high doses of penicillin and hydrocortisone. This case is the first report of anthrax meningitis in a child in Greece and the third reported in the last 15 years. We stress the diagnostic difficulties in atypical cases of cutaneous anthrax and the need for early diagnosis and treatment to avoid spread of infection and appearance of complications such as the usually fatal meningitis.     

北京市一起输入性肺炭疽疫情控制的探讨与思考北大核心CSCD

目的分析输入肺炭疽感染来源,描述流行病学特征,探讨肺炭疽疫情预防控制措施,为类似事件处置积累经验。方法收集患者一般社会学、流行病学、临床表现和病原学检测等信息,按照原卫生部《炭疽病诊断治疗与处置方案(2005年版)》采取预防控制措施。结果该起事件共涉及病例2例,1例肺炭疽,1例皮肤炭疽。实验室检测显示肺炭疽患者胸水荧光实时PCR炭疽芽孢杆菌(以下简称炭疽杆菌)核酸阳性,血清抗体胶体金检测阳性;皮肤炭疽患者血清抗体胶体金检测阳性;3份病死牛牛肉炭疽PCR核酸检测标本阳性,其中1份牛肉分离培养出炭疽杆菌。结论该事件为一起跨省炭疽聚集性疫情,肺炭疽疑似感染来自吸入高压水枪冲刷病死牛剥皮后地面污物过程中产生的含有炭疽杆菌的飞沫、尘埃或气溶胶。     

Cutaneous Anthrax in Adults: A Review of 25 Cases in the Eastern Anatolian Region of Turkey

Abstract. Background: The clinical features, therapy and outcome of anthrax cases from the Elazig province (the eastern Anatolian region) of Turkey seen in our clinic over an 8-year period were reviewed. Patients and Methods: The records of 25 anthrax cases observed in our clinic during the period January 1994 to April 2002 were examined. Results: All cases were cutaneous; 18 (72%) patients exhibited malignant pustules and seven (28%) malignant edema. Three of the patients with a malignant pustule developed anthrax sepsis when admitted to our clinic. All cases were treated with penicillin. One patient who had penicillin allergy was treated with ciprofloxacin. In addition, patients with malignant edema were also treated with systemic corticosteroids (methylprednisolone or dexamethasone). Two patients died due to anthrax sepsis; one case with anthrax sepsis recovered. The mortality rate was 8%. Discussion: Anthrax is still a reality in Turkey. Cutaneous anthrax should be considered in any patient with a painless ulcer with vesicles, edema and a history of exposure to animals or animal products. In our series, penicillin and ciprofloxacin were effective in treatment of anthrax. Our anthrax sepsis case demonstrates that anthrax sepsis is not always fatal if antibiotic treatment is given early after diagnosis.     

Risk factors for human anthrax among contacts of anthrax-infected livestock in Kazakhstan

A retrospective cohort analysis was conducted in Kazakhstan to define modifiable risk factors during seven outbreaks of human anthrax. Fifty-three cases and 255 non-ill persons with an epidemiologic link to an infected animal were enrolled. Cases were 58% male and had a median age of 35 years (range = 5-71). Nearly all cases had cutaneous disease (96%). Two patients (4%) were diagnosed with gastrointestinal disease. Although all cases had some contact with an infected animal other than consumption, in multivariable analysis the act of butchering an animal (relative risk [RR] = 3.6, 95% confidence interval [CI] = 1.5-9.6) and the presence of visible cuts on the hands were associated with anthrax (RR = 3.0, 95% CI = 0.9-9.6). Contact with infected livestock, in particular butchering, is associated with developing anthrax. The risk may be exacerbated by the presence of cuts on the hands at the time of contact with the animal or animal products.     

Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979.

A large epidemic of anthrax that occurred in Sverdlovsk (now Ekaterinburg), Russia, in 1979 resulted in the deaths of many persons. A series of 42 necropsies, representing a majority of the fatalities from this outbreak, consistently revealed pathologic lesions diagnostic of inhalational anthrax, namely hemorrhagic necrosis of the thoracic lymph nodes in the lymphatic drainage of the lungs and hemorrhagic mediastinitis. Bacillus anthracis was recovered in bacterial cultures of 20 cases, and organisms were detected microscopically in the infected tissues of nearly all of the cases. A novel observation was primary focal hemorrhagic necrotizing pneumonia at the apparent portal of entry in 11 cases. Mesenteric lymphadenitis occurred in only 9 cases. This remarkably large series demonstrated the full range of effects of anthrax bacteremia and toxemia (edema especially adjacent to sites of extensive infection and pleural effusions) and hematogenously disseminated infection [hemorrhagic meningitis (21 cases) and multiple gastrointestinal submucosal hemorrhagic lesions (39 cases)].     

Management of anthrax meningitis

Meningitis due to infection with Bacillus anthracis is considered an infrequent manifestation of the disease but one associated with high mortality. The bioterrorism event in the USA in the autumn of 2001 demonstrated our need for a better understanding of anthrax meningitis, as well as management and antimicrobial therapy. However, human clinical trials are not possible and animal experiments to guide such therapy are limited. An approach to the treatment of anthrax meningitis, based on the pathogenicity of B anthracis, the pharmacokinetics and pharmacodynamics of individual antimicrobial agents, studies of anthrax post-exposure prophylaxis in non-human primates, experience with antimicrobial susceptibility patterns of the 2001 outbreak strain, and the clinical experience with inhalational anthrax cases during the 2001 outbreak is presented. These outbreak data, the failure of previous single-drug regimens, the concerns of resistance, and the need for coverage for other causes of bacterial mengingitis suggest initial treatment of suspected anthrax meningitis should anchor on an intravenous fluoroquinolone and should include one or two other agents with activity against B anthracis and good penetration into the central nervous system. Such other agents include penicillin, ampicillin, meropenem, vancomycin, and rifampicin.     

Epidemiology of Haemophilus influenzae meningitis in patients more than 6 years of age

Haemophilus meningitis was found to be rare in those more than 6 years of age in The Netherlands (incidence: 1/10(6)/year). Persons of this age account for only 6-7% of all cases. The histories of a representative sample of 35 of 73 patients over the age of 6 years with Haemophilus influenzae meningitis were reviewed and correlated with the characteristics of the causal strains. Altogether, these patients had suffered 51 episodes of purulent meningitis. Sequelae were found after five of the 35 H. influenzae episodes studied (14%) but none of the patients died during one of these episodes. Of all the patients, 54% had severe predisposing factors, mainly CSF leaks following road traffic accidents or operations, which often led to recurrent bouts of meningitis; these patients were predominantly males. In the patients aged 15-64 years, predisposing factors were present in 74%. Predisposed patients were infected mainly by unencapsulated strains and, as far as type b strains were involved, by uncommon subtypes. Unencapsulated strains were hardly ever able to invade the bloodstream, primarily or secondarily. Careful review of the patient's history is important in this rare disease, because, in many patients, the presence of a CSF fistula may become evident and surgery is likely to prevent recurrences.     

Novel approaches to the treatment of systemic anthrax

Anthrax continues to generate concern as an agent of bioterrorism and as a natural cause of sporadic disease outbreaks. Despite the use of appropriate antimicrobial agents and advanced supportive care, the mortality associated with the systemic disease remains high. This is primarily due to the pathogenic exotoxins produced by Bacillus anthracis as well as other virulence factors of the organism. For this reason, new therapeutic strategies that target events in the pathogenesis of anthrax and may potentially augment antimicrobials are being investigated. These include anti-toxin approaches, such as passive immune-based therapies; non-antimicrobial drugs with activity against anthrax toxin components; and agents that inhibit binding, processing, or assembly of toxins. Adjunct therapies that target spore germination or downstream events in anthrax intoxication are also under investigation. In combination, these modalities may enhance the management of systemic anthrax.     

Pulmonary anthrax

Anthrax is a zoonotic disease caused by Bacillus anthracis. Skin disease is the most common form in humans. Pulmonary anthrax related to the inhalation of airborne germs develops after a silent incubation period of several days and followed by acute respiratory distress. Diagnosis is a difficult task and generally based on demonstration of Bacillus anthracis on direct examination. Despite the sensitivity of B. anthracis to penicillin, treatment is rarely successful.     

Salmonella meningitis and infection with HIV

Patients infected with HIV demonstrate increased susceptibility to serious infections with non-typhoidal salmonellae. However, no cases of salmonella meningitis have been reported in this population. We now report three cases of salmonella meningitis which occurred in a population of 1800 patients with AIDS or AIDS-related complex at our hospitals. The incidence of meningitis complicating salmonella infection in our HIV-infected population appears to be much higher than that reported in non-AIDS patients (7.5 versus 0.15%). All had cerebrospinal fluid parameters consistent with bacterial meningitis, and two of three revealed organisms on cerebrospinal fluid Gram stain. Two presented with a fulminant illness and died despite therapy; the third developed a brain abscess associated with a relapse of meningitis. Salmonella meningitis should be considered as a cause of acute neurological deterioration in patients at risk for HIV-related disease. Relapses may occur, and mortality is high.     

Inhalational anthrax

Anthrax remains a real threat. In a spore form, it is highly infectious and dispersible. The initial symptoms are similar to those of influenza, and the early stage of inhalational anthrax may not be recognized. Early antibiotic treatment is important to achieving a good outcome. Contrary to historical experience. many patients with even advanced anthrax can be saved with aggressive medical care.Prevention of anthrax infections requires vigilant infection control methods as well as a rational prophylactic plan. All health care providers should be familiar with the symptoms and treatment of this disease. It is hoped that future research will clarify tests for early diagnosis, the best methods of prophylaxis, and the most effective treatments. Unfortunately the threat of bioterrorism, and anthrax in particular, is unlikely to go away.     

Injectional anthrax in a heroin skin-popper

Anthrax is rare in western Europe but may arise sporadically in people exposed to animal products from endemic areas. A heroin-injecting drug user presented with a severe soft-tissue infection at the injection site, septic shock, and meningitis. A gram-positive endospore-forming aerobic rod was isolated from the soft tissue and cerebrospinal fluid; confirmation of Bacillus anthracis was made by PCR. Since contaminated heroin was the probable source of infection, this case is of concern and warrants surveillance.     

Emergence of serogroup C meningococcal disease associated with a high mortality rate in Hefei, China

ABSTRACT: BACKGROUND: Neisseria meningitidis serogroup C has emerged as a cause of epidemic disease in Hefei. The establishment of serogroup C as the predominant cause of endemic disease has not been described. METHODS: We conducted national laboratory-based surveillance for invasive meningococcal disease during 2000--2010. Isolates were characterized by pulsed-field gel electrophoresis and multilocus sequence typing. RESULTS: A total of 845 cases of invasive meningococcal disease were reported. The incidence increased from 1.25 cases per 100,000 population in 2000 to 3.14 cases per 100,000 in 2003 (p < 0.001), and peaked at 8.43 cases per 100,000 in 2005. The increase was mainly the result of an increase in the incidence of serogroup C disease. Serogroup C disease increased from 2/23 (9%) meningococcal cases and 0.11 cases per 100,000 in 2000 to 33/58 (57%) cases and 1.76 cases per 100,000 in 2003 (p < 0.01). Patients infected with serogroup C had serious complications more frequently than those infected with other serogroups. Specifically, 161/493 (32.7%) cases infected with serogroup C had at least one complication. The case-fatality rate of serogroup C meningitis was 11.4%, significantly higher than for serogroup A meningitis (5.3%, p = 0.021). Among patients with meningococcal disease, factors associated with death in univariate analysis were age of 15--24 years, infection with serogroup C, and meningococcemia. CONCLUSIONS: The incidence of meningococcal disease has substantially increased and serogroup C has become endemic in Hefei. The serogroup C strain has caused more severe disease than the previously predominant serogroup A strain.