Chapter 213

Cutaneous
Manifestations of
Biologic, Chemical,
and Radiologic Attacks
Scott A. Norton

BIOLOGIC WEAPONS
Anthrax Transmission.
The infectious propagule of Bacillus anthracis is
its spore, not the activated bacillus. Under harsh
environmental conditions, anthrax bacilli revert
into spores that can remain dormant in soil or
animal products for decades, impervious to heat,
cold, desiccation, and solar radiation. These hardy
spores are 12 m in diameter and are easily introduced into open skin, aerosolized and inhaled, or
ingested. Once in the hospitable environment of
human tissue, the spores germinate, transforming
into activated bacilli (2.5 10 m) that generate
disease-causing toxins but pose no risk of further
direct human-to-human contagion.12
When spores enter the body, they are ingested by
host macrophages where they transform into activated bacilli. These macrophages may be carried to
regional lymphnodes and produce a hemorrhagic
lymphadenitis. If bacteremia ensues, septicemia
with shock and often meningitis may follow. The
activated bacilli produce exotoxins and virulence
factors. A pair of toxins, designated edema toxin
and lethal toxin, consists of a pair of noncovalently
linked protein components4: edema toxin consists
of edema factor (EF) plus protective antigen (PA);
lethal toxin consists of lethal factor (LF) plus PA. PA
binds to a surface receptor on most mammalian
cells and is subsequently cleaved by furin-like
proteases. LF is capable of killing macrophages or,
at lower concentrations, inducing them to overproduce specific cytokines (TNF-, interleukin-1).4
These actions are probably responsible for the
sudden death from toxicity that occurs with high
concentrations of bacteremia (107108 bacilli per
milliliter of blood) and terminally high lethal toxin
levels.13

Differential Diagnosis.
Acute staphylococcal cellulitis with a central pustular lesion or an abscess with a necrotic eschar, particularly those due to methicillin-resistant Staphylococcus aureus (MRSA), may be confused with early
anthrax. The pyogenic infections, however, are
usually very painful and tender, and the etiologic
agent is usually present on Gram-stain examination.
Differential diagnosis of cutaneous anthrax includes
ecthyma (caused by Streptococcus pyogenes and
usually without edema or systemic manifestations),
ecthyma gangrenosum (usually in the setting of
neutropenia and Pseudomonas aeruginosa bacteremia), orf (caused by a parapoxvirus through contact
with sheep or goats; vesicopustular lesions without
gelatinous edema), and a brown recluse spider bite
(causes pain with incipient necrosis).
GASTROINTESTINAL ANTHRAX.
Another form of anthrax that can cause highly lethal outbreaks is gastrointestinal anthrax, although
this is regarded as an unlikely route for intentional
spread of anthrax spores. Gastrointestinal anthrax
occurs after the ingestion of raw or undercooked
meat-infected animals. Although vegetative bacteria are killed by gastric acid, the anthrax spores
are resistant and are activated when in the caecum
or colon. Gastrointestinal anthrax produces acute
abdominal pain with distension and fever, often
accompanied by hematemesis and bloody diarrhea.
Unless there are other confirmed cases in a community, the diagnosis is rarely suspected, hence the
high mortality rates, due to shock and secondary
sepsis, with this form of anthrax. An uncommon
oropharyngeal variant occurs if the spores activate
and penetrate the oropharyngeal mucosa before
entering the stomach. Because contaminated meat
may be eaten by many people in a family or community, gastrointestinal anthrax usually presents in
dramatic outbreaks, rather than as individual cases.
The largest such outbreak is suspected to have
occurred in 1770 in Haiti where perhaps 15,000
people died after consumption of uncooked beef
during a time of civil upheaval.17 A case on gastrointestinal anthrax was reported in a New Hampshire
woman in 2009. Presumably she inadvertently
ingested anthrax spores that had been on the
leather surface of a West African drum that she was
playing.18

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