Volume 20, Number 7—July 2014
CME ACTIVITY - Synopsis
Lessons for Control of Heroin-Associated Anthrax in Europe from 2009–2010 Outbreak Case Studies, London, UK
||HIV, hepatitis C
||Hepatitis B, hepatitis C, thromboembolic disease
||Hepatitis C, left femoral artery pseudoaneurysm
|Route of infection
||Subcutaneous injection to left thigh 3 d before admission
||Subcutaneous injection to right buttock 1 wk before admission
||Injected into left femoral artery
|Site affected when patient sought treatment
||Extensive involvement: painless edema and blistering of the left thigh, lower abdomen, genitals
||Right buttock erythematous, swollen, edematous, and painful; edema extended to genitals
||Pulsatile mass at left groin area; no edema or swelling evident
||Extensive debridement by general surgery and gynecology performed on 2 occasions; skin graft applied later
||Early, limited debridement performed on d 1 of hospitalization. Skin graft applied later
||On hospital d 1, surgery performed to repair left femoral artery pseudoaneurysm and debridement; further debridement performed at d 19
|Anthrax testing results|
|Culture||Blood culture of specimen drawn on admission positive in <24 h||Blood and tissue cultured on admission positive 24 h after admission||Blood and tissue cultured on admission negative|
|Initial antibiotic drugs
||Ceftriaxone, clindamycin, vancomycin
||Clindamycin, ciprofloxacin, flucloxacillin, vancomycin, gentamicin
||Clindamycin, ciprofloxacin, flucloxacillin, benzylpenicillin, metronidazole
||Initially lucid and comfortable but hemodynamically unstable. Debridement on 2 occasions. Anthrax PCR post–antibiotic drug treatment negative; coagulopathy resolved by day 29 with normal platelets and clotting studies. On day 31, brain stem ischemia developed; died on d 50 after airway complications.
||After initial debridement, electively intubated to treat edema causing respiratory compromise. Received AIGIV within 24 h of admission. Vacuum-assisted therapy pump was used, then skin graft, with good outcome. Recovered and was discharged to complete 60 d of ciprofloxacin and clindamycin.
||After first surgery on hospital d 1, continued broad-spectrum antibiotic drugs for 10 d. Received a further 14 d of broad-spectrum antibiotic drugs after debridement on d 19. Made a good recovery and was discharged home. Strongly positive serologic results subsequently received.
|Test results for blood samples taken at admission (reference range)†|
|Leukocyte count (4.2–11.2 x 109 L)||23.1||16.8||10.1|
|Neutrophils (2.0–7.1 x 109/L)||14.6||14.6||4.9|
|CRP (0–4 mg/L)||179||71||230|
|Hemoglobin (13.0–16.8 g/dL)||15.7||6.7||9.8|
|Platelets (130–370 x 109/L)||374||30||238|
|Creatinine (60–125 μmol/L)||385||488||137|
|Albumin (30–45 g/L)||24||23||30|
*Patients 1, 2, and 3 represent the diversity of the cases seen and the spectrum of manifestation caused by heroin-associated anthrax. Clinical features associated with this condition include the degree of edema present, the absence of the eschar associated with cutaneous anthrax, and the biphasic nature of the illness; in the severe cases, Patients 1 and 2 experienced multiorgan dysfunction and coagulopathy. AIGIV, anthrax immune globulin intravenous; CRP, C-reactive protein; INR, international normalized ratio.
†Reference ranges from Imperial College Healthcare (http://www.imperial.nhs.uk/services/pathology/index.htm).