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Biological Terrorism

Biological Terrorism. HARRT 2004. Early Symptoms/Signs Fever, Malaise, Fatigue, Chills, Myalgia Cough Delayed Symptoms/Signs Stridor Dyspnea Pleural Effusions Respiratory Distress Chest Pain Edema Abdominal Pain - GI Type. Delayed Symptoms/Signs (continued)

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Biological Terrorism

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  1. Biological Terrorism HARRT 2004

  2. Early Symptoms/Signs Fever, Malaise, Fatigue, Chills, Myalgia Cough Delayed Symptoms/Signs Stridor Dyspnea Pleural Effusions Respiratory Distress Chest Pain Edema Abdominal Pain - GI Type Delayed Symptoms/Signs (continued) Meningitis (Hemorrhagic CSF in 50%) Septic Shock Painless Necrotic Ulcers with Black Base - Dermal Contact Classic Symptoms/Signs WIDENED MEDIASTINUM Anthrax (Inhalational) Bacillus anthracis

  3. Anthrax (Inhalational) Bacillus anthracis • Bioterrorism Mode of Dissemination: Aerosol, (Cutaneous?) • Incubation Period: 1-6d (usually within 48h) • Duration of Illness: Days • Lethality: High (80-90%) • Transmissibility: Low (cutaneous Anthrax only)

  4. Flu vs. Anthrax (low risk population)(MMWR 2001; 50(44):984-986) • Nasal congestion/rhinorrhea: Think flu, not anthrax • CXR abnormal? - Consider CT to r/o mediastinal pathology • Dyspnea, chest discomfort, pleuritic pain: Think anthrax • Rapid flu tests: Not helpful.

  5. Mass Screening for Inhalational Anthrax: Lessons LearnedAnn Intern Med 2003; 139:337345 • Sources: 28 cases of inhalational anthrax (1920-2001); 2762 cases of influenza & 1932 cases on noninfluenza viral resp. disease • Results: • Fever/cough don’t discriminate • Anthrax: • Nonheadache neurologic sx (LOC, confusion, blurred vision, dizziness) • Dyspnea • Nausea or vomiting • Abnormal lung sounds • Viral resp. tract infection: • Rhinorrhea • Sore throat

  6. Exposed Patients One Screening Protocol Ann Intern Med 2003;139:337-345 Any nonheadache Neurologic Symptoms? YES NO NO Fever/chills or Cough? YES Any dyspnea or Nausea/vomiting or Abnormal lung Exam? NO YES Any rhinorrhea or Sore throat? NO Consider sending To hospital for Definitive Testing & Initiation Of therapy YES Consider to home with Prophylactic Antibiotics and Follow-up instructions

  7. Median age: 56 yr. Age range: 43-73 yr. Sex: 7 males I.P.: 7d (range: 5-11d) Fever: 9 Sweats/chills: 6 Malaise: 8 Cough: 9 Chest discomfort/pleuritic pain: 8 Abdominal pain, N&V: 5 Dyspnea: 7 Headache: 5 Myalgias: 4 Sore throat: 2 WBC: WNL/slight increase CXR/CT: Pleural effusions (7), infiltrates (7), mediastinal lymphadenopathy 10 confirmed/suspected inhalational anthrax cases (MMWR 2001; 50(43):941-948)

  8. Inhalational anthrax case report • 61 year old female • Oct. 25: Malaise, myalgias • Oct. 26-27: Dyspnea, chest discomfort, productive cough, bloody sputum • October 28: To ER in respiratory distress; fever, widened mediastinum and bilateral pleural effusions on CXR • Oct. 31: Death • MMWR 2001: 50 (43); 941-8.

  9. 1 2 The Connecticut Case 3

  10. Cutaneous anthrax case review (11)(MMWR 2001; 50(43):941-948) • I.P.: 5d (Range: 1-10d) • Location: Forearm, neck, chest, fingers • Progression: Papule vesicle ulcer black eschar • Painless with tingling or pruritic sensation • Lethality (historically): <20%

  11. 7 month old New Yorker with microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency

  12. Cutaneous anthrax case report • 34 year old male • Oct. 12-15: Handling mail • Oct. 19: Small, erythematous, pruritic papule on left forearm • Oct. 19-20: Vesicle • Oct. 22-25: Increasingly larger eschar with erythema, edema, and induration

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