ARTICLE
Auteur(s) : Anthony
Karpouzis1, Maria Panopoulou2, Grazia
Bazzano1, Anastassia Grapsa2, Efstratios
Maltezos3, Sofia Ktenidou-Kartali2,
Constantin Kouskoukis1
1University Dept of Dermatology, Faculty of Medicine.
Democritus University of Thrace, Greece
2University Dept of Microbiology Faculty of Medicine.
Democritus University of Thrace, Greece
3University Dept of Internal Medicine, Faculty of
Medicine. Democritus University of Thrace, Greece
accepté le 2 Mai 2007
Nowadays, verification of Bacillus anthracis depends on the kind of
samples taken and may be based on morphological elements of this
Bacillus as well as on certain cultural and biochemical properties
(in order to discriminate from Bacillus cereus) [1, 2]. An
electrophoretic immunotransblot assay for antibodies to Bacillus
anthracis toxin antigens may demonstrate a diagnostic titer to
anthrax protective antigen and lethal factor [3, 4]. A Bacillus
anthracis-specific polymerase chain reaction assay is also
available, detecting 5 target gene sequences present in the
chromosome and virulence plasmids pX01 and pX02.[5] The use of the
successful development of a highly effective livestock vaccine
remains to this day, the most important of all control measures [6,
7].The disease in humans is still prevalent in many parts of
Africa, South East, Asia, China, Indian subcontinent, Central
America, certain regions of Eastern and Southern Europe, the Middle
East, the Russian Federation and South America [1]. Only occasional
sporadic cases are seen in other areas. Cutaneous anthrax accounts
for 95-99% of human cases. It is primarily a local infection that,
untreated, may cause systemic disease with up to 20% mortality,
although with antibiotic treatment, the mortality is less than 1%
[1]. The case reported below is characterized by original clinical
particularities.
Case report
A 60-year-old male patient presented at the Emergency Dept because
of a high fever and the sudden appearance of a particularly raised
and unyielding hemorrhagic bulle (3 cm in diameter) on the
flexion surface of the left forearm (figure 1A). He reported
the appearance of a small vesiculopapule (5 mm in diameter) on
the site of the bulla, one day before the appearance of the bulla.
This bulla was characterized by an erythematous and oedematous
underlying base. The patient was a shepherd by profession and
reported the slaughter of a pig one month previously (in summer).
We asked patient about insect bites (by bloodsucking flies or
mosquitoes) but we received a clearly negative answer. The patient
was admitted in the University Dermatological Clinic, with a
clinical suspicion of cutaneous anthrax and an intravenous
treatment with clindamycin and ciprofloxacin was administered. Two
days after admission, new hemorrhagic bullae appeared on the left
forearm and arm so that the whole erythemato-oedemato-bullous
eruption extended from the left shoulder to the hand. Corresponding
axillary lymph nodes were swollen, the entire upper limb was
extremely inflexible. Investigations revealed leukocytosis,
hyponatriemia, hypocalcemia, hypoalbuminemia, increased prothrombin
time and increased lactate dehydrogenase. Chest X-rays, an
electrocardiogram and abdomen ultrasonography were normal. Blood
culture and Gram stain smears directly of the bullae hemorrhagic
content were negative. Culture of the bullae content in sheep blood
agar developed plane, non hemolytic, light ashen (with medusa-head
appearance) colonies. Gram stain preparations of colonies on
nutrient agar revealed large gram positive bacilli with central
spores. Catalase production was positive while the mobility test
(in semi-solid agar 0.5%) was negative. Bacillus anthracis
biochemical verification was obtained by the Api50CH panel with
Api50 CHB/E medium (Bio-Merieux). Improvement of the clinical
aspect of the patient’s skin started from the sixth day after
admission (figure
1B), fever lasted for 13 days. Intravenous clindamycin was
administered for 5 days and intravenous ciprofloxacin for 14 days.
Local care (during 14 days of nursing) of the lesions included
povidone iodine, fusidic acid dressing and topical alkane oil,
sterilized gauzes and loose bandage. The patient came out of the
hospital in a satisfactory clinical situation and oral
ciprofloxacin continued for 45 days more. A stony hard (10 cm
in diameter) raised black eschar on the forearm replaced the bullae
(figure 2) and
lasted for three months, afterwards it detached spontaneously and
finally a 2 cm brownish-grey crust remained in the middle of
the surrounding fibrotic tissue.
Discussion
From 1996 to 2006 (over 11 years in Greece), 17 cases of cutaneous
anthrax have been officially reported to the Center of Special
Infections Control (National Public Health Authority in Athens).
Our patient constitutes the 17th case in Greece and the
first case in Thrace, Northern Greece. Among these 17 cases, 12
cases concern male patients, 3 cases females while for the other
two ones, the sex in unknown. 7 patients were from 45 to 64 years
old, 3 patients were more than 65 years old, 2 from 25 to 44 years
old and only one subject was between 15 and 24-years-old.
Systematization develops from lymphohaematogeneous dissemination
of microorganisms from the primary skin focus and may include
painful lymphangitis, tender lymphadenopathy and septicaemia [8].
Untreated cutaneous anthrax of children may evolve to meningitis
[9]. Additionally, an infant with skin anthrax has been reported,
who developed severe systemic illness (despite early treatment with
antibiotics) including microangiopathic hemolytic anemia, renal
involvement, coagulopathy and hyponatremia [10]. Anthrax skin
lesions usually remain small (< 2 cm in diameter), and
rarely become very extensive (> 10 cm). Moreover, two
cases of particularly extensive skin anthrax (accompanied by
swelling of the corresponding lymph nodes) in diabetic subjects,
have been recently published [11, 12].
Our patient had particularly extensive skin anthrax, which
developed (a) following the slaughtering of an omnivorous (and not
exclusively herbivorous) animal, such as a pig, (b) the infection
was extensive, although the patient was not prone to the extension
or generalization of infection (for example on account of a
coexisting diabetes mellitus or another immunodepressor
factor).
The period between infection (via a cut, abrasion or insect
bite) and the first appearance of a small vesiculopapule is usually
1 to 3 days [1, 2], whereas this time reached one month in our
case. The stony hard black escharr detached spontaneously. Surgical
intervention is really necessary only when scarring affects a
function such as the movement of an eyelid or if the escharr is
exceptionally large and skin grafting is called for [13].
The fever, the extension of the eruption, the swelling of the
ipsilateral respective lymph nodes as well as the generalized
debility of our patient, might suggest either a secondary
staphylococcal infection (which may occur with underlying skin
anthrax), or the beginning of a systematization of the skin anthrax
infection. We preferred to administer intravenously a regimen of
two antibiotics (ciprofloxacin and clindamycin) for the following
reasons: (a) the clinical aspect raised suspicion of anthrax but
this diagnosis was not still verified at the time of admission, (b)
eventual systematization of skin anthrax or secondary infection by
cocci in particular and (c) the use of spores of a b-lactamase
positive anthrax strain as a bioterrorism agent, imposed on United
States Center for Disease Control and Prevention to recommend
ciprofloxacin or doxycycline for the management of anthrax (instead
of penicillin) [14].
In conclusion, cutaneous anthrax is usually a self-limiting
condition and remains localized. However, without treatment (even
in the absence of any immunodepressant or immunodeficient
condition) it may evolve to an extensive cutaneous form with
respective lymphademopathy and afterwards to a severe systemic
disease. Thus, if cutaneous anthrax is clinically suspected,
patients should be treated by the appropriate antibiotics.
Moreover, it is very important (for the most effective management
of patients and for public health protection) to verify Bacillus
anthracis incrimination by isolating the microorganism, using the
available laboratory methods.
Acknowledgements
Financial support: none. Conflict of interest: none.
References
1 Dixon TC, Meselson M, Guillemin J, Hanna PC.
Anthrax. N Engl J Med 1999; 341: 815-26.
2 Turnbull PCB, Doganay M, Lindeque PM,
Aygen B, McLaughlin J. Serology and anthrax in humans and
Etosha National Park wildlife. Epidemiol Infect 1992; 108:
299-313.
3 Ezzell JW, Ivins BE, Leppla SH.
Immunoelectrophoretic analysis, toxicity and kinetics of in vitro
production of the protective antigen and lethal factor components
of Bacillus anthracis toxin. Infect Immun 1984; 45: 761-7.
4 Quinn CP, Shone CC, Turnbull PCB,
Melling J. Purification of anthrax toxin components by
high-performance anion-exchange, gel-filtration and
hydrophobic-interaction chromatography. Biochem J 1988; 252:
753-8.
5 Ramisse V, Patra G, Garrigue H,
Guesdon JL, Mock M. Identification and characterization
of Bacillus anthracis by multiplex P.C.R. analysis of sequences on
plasmids pX01 and pX02 and chromosomal DNA. FEMS Microbiol Lett
1996; 145: 9-16.
6 Turnbull PC. Anthrax vaccines: past, present and future.
Vaccine 1991; 9: 533-9.
7 Fellows PF, Linscott MK, Ivins BE,
Pitt ML, Rossi CA, Gibbs PH, Friedlander AM.
Efficacy of a human anthrax vaccine in guinea pigs, rabbits and
rhesus macaques against challenge by Bacillus anthracis isolates of
diverse geographical origin. Vaccine 2001; 19: 3241-7.
8 Wenner KA, Kenner JR. Anthrax. Derm Clin 2004; 22:
247-56.
9 Tahernia AC, Hashemi G. Survival in anthrax
meningitis. Pediatrics 1972; 50: 329-33.
10 Freedman A, Afonja O, Chang MW,
Mostashari F, Blaser M, Perez-Perez G,
Lazarus H, Schacht R, Guttenberg J, Traister M,
Borkowsky W. Cutaneous Anthrax associated with
microangiopathic haemolytic anemia and coagulopathy in a
7-month-old infant. JAMA 2002; 287: 869-74.
11 Erkek E, Ayaslioglu E, Beygo B, Ozluk U.
An unusually extensive case of cutaneous anthrax in a patient with
type II diabetes mellitus. Clin Exp Dermatol 2005; 30: 652-4.
12 Kolbe A, Yuen MG, Doyle BK. A case of human
cutaneous anthrax. Med J Aust 2006; 185(5): 281-2.
13 Godyn JJ, Reyes L, Siderits E, Hazra A.
Cutaneous anthrax: conservative or surgical treatment? Adv Skin
Wound Care 2005; 18(3): 146-50.
14 Centers for Disease Control and Prevention. Update:
investigation of bioterrorism-related anthrax and interim
guidelines for exposure management and antimicrobial therapy.
October 2001. MMWR Morb Mortal Wkly Rep 2001; 50: 909-19.
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