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
Aula Abbara, Tim Brooks, Graham P. Taylor, Marianne Nolan, Hugo Donaldson, Maribel Manikon, and Alison Holmes
Table
Details of 3 heroin-associated anthrax patients from the 2009–2010anthraxoutbreak, London, United Kingdom*
| Characteristic |
Patient 1 |
Patient 2 |
Patient 3 |
| Age, y/sex |
43/F |
30/M |
60/M |
| Comorbidities |
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 |
| Surgery |
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 |
| Serologic | Positive | Positive | Positive |
| PCR |
Positive |
Positive |
Negative |
| Initial antibiotic drugs |
Ceftriaxone, clindamycin, vancomycin |
Clindamycin, ciprofloxacin, flucloxacillin, vancomycin, gentamicin |
Clindamycin, ciprofloxacin, flucloxacillin, benzylpenicillin, metronidazole |
| Outcome |
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 |
| INR (1.0) | 4.4 | 1.5 | 1.0 |
| 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).
Page created: June 12, 2014
Page updated: June 12, 2014
Page reviewed: June 12, 2014
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