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ANTHRAX

The anthrax bacillus, Bacillus anthracis, was the first


bacterium shown to be the cause of a disease- Kochs
Postulate
In 1877, Robert Koch grew the organism in pure culture,
demonstrated its ability to form endospores, and
produced experimental anthrax by injecting it into
animals.
Anthrax is a disease of domesticated and wild animals
Men suffer from anthrax occasionally due to close
contact with infected animal or animal products

Bacillus anthracis
Gram positive rods
Capsulated ( Protein) Capsule form in animal tissue and in special
laboratory condition ( 5% CO2)
Forms endospore, centrally located, do not form in animal tissues
MacFadyean ( Polychrome methylene blue) stain blue bacilli
with purple capsule
Aerobic/ Facultative anerobe

Robert Koch's original micrographs of the anthrax bacillus

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Bacillus anthracis. Gram stain. The cells have characteristic


squared ends. The endospores are ellipsoidal shaped and located
centrally in the sporangium. The spores are highly refractile to
light and resistant to staining.
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Epiedemiology
Distribution worldwide
Not common in West. Common in Africa ( Zimbabwe),
S.E. Asia, China, South America, Turkey, Pakistan, India
Human to human or animal to animal transmission is rare
( not contagious)
Grazing animals become infected through ingestion of
spores in the soil ( Carcasses become the source)
Epidemic : A. Spread to contiguous geographic areas by
infected animal
B. Non contiguous geographic areas by
- biting flies ( Zimbabwe)
- Contaminated surface water pool
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Pathogenesis
Endospores
(Abrasion, inhalation, ingestion)
Death

Introduced

Septicemia

Phagocytosed by Macrophages

10 7 to 10 8/ml

Regional LNs

Blood stream

Multiply in Lymphatics

Germinate inside Macrophages

Release
Vegetative Forms

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Clinically three forms of Human anthrax occur


A. Cutaneous anthrax
B. Pulmonary anthrax
C. Intestinal anthrax
Broadly can be classified into
Non Industrial/Agricultural ( Through infected animals):
Cutaneous anthrax
Rarely intestinal anthrax
Industrial Anthrax ( Through animal products):
Mostly through animal products( wools, hair, hides, bones)
Likely to develop Cutaneous and pulmonary anthrax ( inhalation)
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Cutaneous Anthrax
Mainly in professionals( Veterinarian, butcher, Zoo keeper
Spores infect skin- a characteristic gelatinous edema develops at the
site (Papule- Vesicle-Malignant Pustule- Necrotic ulcer)
80-90% heal spontaneously ( 2-6wks)
0-20% progressive disease develop septicemia
95-99% of all human anthrax occur as cutaneous anthrax
Intestinal Anthrax
Due to in ingestion of infected carcasses
Mucosal lesion to the lymphatic system
Rare in developed countries
Extremely high mortality rate

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PULMONARY ANTHRAX
Require very high infective dose ( > 10,000 spores)
Acquired through inhalation of spores ( Bioterrorism - aerosol)
Present with symptoms of severe respiratory infection( High fever &
Chest pain)
Haemorrhagic mediastinitis
Progress to septicemia very rapidly
10 7 to 10 9 bacilli/ ml of blood at the time of death
Mortality rate is very high > 95%
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Meningitis
Meningitis has been reported in association with cutaneous, inhalation,
and gastrointestinal anthrax cases
About one-half of patients with inhalation anthrax will develop
hemorrhagic meningitis

DIFFERENTIAL DIAGNOSIS OF ANTHRAX


CUTANEOUS ANTHRAX
Boils, Erysipelas, Cutaneous TB, Leprosy, Plague, Vaccinia, Rickettsial pox,
tularemia
INTESTINAL ANTHRAX
Typhoid fever, Acute Gastroenteritis, Tularemia, Peritonitis, Peptic ulcer,
Mechanical obstruction
PULMONARY ANTHRAX
Viral pneumonia, Mycoplasma. Psittacosis, Legionnaires disease, Q fever,
Histoplasmosis, Coccidiodomycosis, Silicosis, Sarcoidosis
Meningeal Anthrax : Sometime manifest as meningitis
D/D : Bacterial meningitis
Aseptic meningitis
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VIRULENCE FACTORS
Anthrax Toxin Complex of proteins ( all the components thermolabile)
A. Protective antigen
B. Edema factor
C. Lethal Factor
Protein capsule Poly D Glutamic acid capsule
- Inhibits phagocytosis ( Unencapsulated strains
nonpathogenic)

LABORATORY DIAGNOSIS
Few points to remember
Anthrax is not highly contagious
Cutaneous anthrax is not lethal and is readily treated with
common antibiotics
ID for human pulmonary / intestinal infection is > 10,000 spores
SPECIMEN TO COLLECT ( HUMAN ANTHRAX)
Disposable gloves, masks, overalls, boots, head gear and dust mask
Disposable items Autoclave and incinerate
Cutaneous anthrax: Vesicular exudate swabs and capillary tube aspirate
Intestinal anthrax: - Stool sample - isolate guinea pig inoculation
- Blood( venipuncture) smear examination for bacilli
- Peritoneal fluid for culture
- Paired sera for Ab

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Pulmonary anthrax:
Specimens of blood obtained prior to antimicrobial therapy should be sent
for routine culture and for polymerase chain reaction (PCR) testing at a
Laboratory Response Network (LRN) laboratory
Pleural fluid, if present, for Gram stain, culture, and PCR
Cerebrospinal fluid, in patients with meningeal signs, for Gram stain,
culture, and PCR
Acute and convalescent serum samples for serologic testing
Pleural and/or bronchial biopsies for immunohistochemistry, if other tests
are negative

SAMPLES FROM ANIMAL


Sudden death of animal in areas where anthrax was reported earlier
Carcasses 1 or 2 day old
Aspirate blood - MacFadyean stain for bacilli
Direct demonstration by IFA
Direct plating on blood agar
Putrefying carcasses
Blood, tissue and hide
Culture on selective medium
Soil sample from the areas where the carcass as lying
Serological assay
ELISA: based on anthrax toxin ( PA, LF and EF) for routine confirmation and
vaccine response)
Molecular techniques ( Only in the referral laboratories):
- RFLP
- PCR Fingerprinting
Animal Inoculation: Guinea pig and mice inoculation
Culture is confirmed by gamma phage lysis ( PlyG lysin enzyme- g phage)

TREATMENT
Antibiotics should be given to unvaccinated individuals exposed to inhalation
anthrax.
Penicillin, tetracyclines and fluoroquinolones are effective if administered before the
onset of lymphatic spread or septicemia
Antibiotic treatment is effective in cutaneous anthrax
Inhalation anthrax can be effectively treated with antibiotics administered prior to
lymphatic spread or septicemia
INITIAL THERAPY
Adults

Ciproflox
( 400mg iv BDX60days)

Children Ciproflox
20-30mg/kgbodywt ivX60days

OPTIMAL THERAPY
Penicillin G 4 mu iv qdsX60days
Doxycycline 100mg iv BDX60 days
Penicllin G 50,000 u/kg X 60 days

Alternatives Amox, Tetracycline, Chloramphenicol, Erythromycin, Streptomycin


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Although initial therapy should be intravenous, patients may


be switched to oral therapy once they are stable, usually
after 14 to 21 days of intravenous therapy.
A total duration of treatment of 60 days (combination of
intravenous and oral therapy) should be given

Vaccine against Anthrax


Killed bacilli and/or capsular antigens produce no significant immunity.
A nonencapsulated toxigenic strain (Sterne Strain) has been used effectively in
livestock.
Vaccine for humans: ( avirulent and nonencapsulated) sublethal amounts of the toxin
produced
Licensed in the U.S. is a preparation of the protective antigen (PA)
Dose:

A. 3 doses subcutaneously at the interval of 2 wks


B. Followed by three additional doses at 6,12 and 18 months
C. Annual booster dose
Who are to be vaccinated

- Professionals ( Veternarians, butcher, Zoo keeper, Wild life workers, Forest guards)
- Military personnels

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Anthrax and Biological Warfare


Countries > 10 countries in the world
Clouds of spores of Anthrax bacilli aerosol ( war heads filled with anthrax spores)
- Through dried spores in envelops
September 9/11 WTO attack
Postal workers affected Inhalation anthrax ( 40% mortality)
US Columbia, Florida, New Jersey, N. York
Other parts of the world
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