Anthrax of the skin A22.0

Author: Prof. Dr. med. Peter Altmeyer

All authors of this article

Last updated on: 29.10.2020

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Synonym(s)

Anthrax; Furunculus maligna; Pustula maligna; Skin anthrax

History
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Koch, 1876

Definition
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A notifiable zoonosis with Bacillus anthracis, which occurs very rarely in humans and is widespread worldwide. The disease anthrax manifests itself in 4 main forms:

  • Skin anthrax (incubation period hours to days after cutaneous inoculation of the germs)
  • Pulmonary anthrax (incubation period 4-6 days after inhalation of the germs)
  • Gastrointestinal anthrax (incubation period 1-3 days after oral uptake of the germs)
  • Injection anthrax (incubation time 1-3 days after injection of the germ-containing material)

Pathogen
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Bacillus anthracis (large gram-positive rod; width: 1-2 μm; length: 3-10 μm; toxin-forming agent).

Occurrence/Epidemiology
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Spread throughout the world, especially in livestock areas (ruminants). Very rarely in industrialized countries; preferred in warmer climates, e.g. in Southeast Europe, South America, Africa, Southeast Asia.

Etiopathogenesis
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Infection through contact with spores of the pathogen Bacillus anthracis from contaminated animal materials (organs, fur, wool, fertiliser with bone meal). The spores are extremely resistant and can survive for years in animal products or in the animal environment (pastures, stables, feed). After inoculation of the spores (skin injury, inhalation or consumption) the growth of the pathogen begins and a protein capsule is formed which protects it from phagocytosis. It also produces various exotoxins (lethal toxin, edema toxin).

Manifestation
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Mostly work-related infection among others in agricultural workers, butchers, leather workers, furriers.

Mostly cutaneous manifestation (95%), more rarely pulmonary anthrax after inhalation inoculation (5%) or intestinal anthrax after oral uptake of spores (< 1%).

Clinical features
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Incubation time: hours up to 6 days.

Skin anthrax: The pathogen enters the skin through a small lesion. At the inoculation site, development of an unremarkable red spot: increasing infiltration followed by rapid formation of an inflammatory nodule or pustule; rapid spread, haemorrhagic bladder; blackish necrosis with considerable collateral swelling, highly inflammatory gelatinous infiltrate and satellite vesicles; this clinical finding is also called "anthrax carbuncle". Important: unlike a boil caused by staphlococci, anthrax carbuncle is usually not painful! It is characterized by early onset of mild regional lymphangitis and lymphadenitis, but also by tiredness, malaise, headaches with varying temperatures, including high febrile temperatures. Risk of sepsis. After 7-10 days the symptoms regress. The complete healing of the anthrax carbuncle can take weeks. In rare cases: secondary infections.

Anthrax pneumonia: after collection of spore-containing dust, development of severe bronchial pneumonia with high fever within a few days. Untreated after 2-3 days of sepsis with fatal consequences.

Intestinal anthrax (very rare): after consumption of infected meat

Diagnosis
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The decisive factor is a possible exposure in the anamnesis if the clinic is appropriate.

Detection of the pathogen in the smear preparation of the skin lesion ( Gram stain) or in culturally in special laboratories (skin lesion, sputum, stool, blood). If necessary 16S rRNA- PCR and gene sequencing.

Cave! Due to the danger of generalization, surgical manipulation (biopsies) should be avoided in cases of anthrax carbuncles.

Complication(s)
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Anthrax sepsis with infestation of CNS and lungs; possible lethal outcome.

General therapy
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Isolation of the patient.

External therapy
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Dry, e.g. with zinc powder.

Internal therapy
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Early use of penicillin G in a medium dosage (2-4 million IU/day i.v.) to prevent dissemination of the pathogens. In severe cases or generalisation short infusion of penicillin G 2-4 times/day 10 million IU, then reduction of the dose to 2 million IU/day for 14 days.

Alternatively: Ciprofloxacin (e.g. Ciprobay) 2 times/day 400 mg i.v. or Tetracycline (e.g. Achromycin) 3-4 times/day 0.5-1.0 g p.o. or Erythromycin (e.g. Erythrocin) 3-4 times/day 250-500 mg i.v. or p.o.

Note(s)
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Misuse as a biological terrorist weapon in the USA (see also anthrax pneumonia)

Literature
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  1. Bartlett JG et al (2002) Management of anthrax. Clin Infect Dis 35: 851-858
  2. Brook I (2002) The prophylaxis and treatment of anthrax. Int J Antimicrob Agents 20: 320-325
  3. Denk A et al(2015) Cutaneous anthrax: evaluation of 28 cases in the Eastern Anatolian region of Turkey
    .cutan ocul toxicol. 2015 Jul 30:1-4 [Epub ahead of print]
  4. Koch R (1876) The etiology of anthrax, based on the history of development of Bacillus anthracis. Contributions to plant biology 2: 277-310
  5. Lawn SD et al (2003) A black necrotic ulcer. Lancet 361: 1518
  6. McGovern TW, Norton SA (2002) Recognition and management of anthrax. N Engl J Med 346: 943-945
  7. Pasteur L, Chamberlain CE, Roux E (1881) Compte rendu sommaire des experiences faites a Pouilly-le-Fort, pres Melun, sur la vaccination charbonneuse. Comptes Rendus des seances De LíAcademie des Sciences 92: 1378-1383
  8. Prince AS (2003) The host response to anthrax lethal toxin: unexpected observations. J Clin Invest 112: 656-658
  9. Spencer RC (2003) Bacillus anthracis. J Clin Pathol 56: 182-187
  10. Tutrone WD et al (2002) Cutaneous anthrax: a concise review. Cutis 69: 27-33

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