Thread: The anthrax verdict - Case Reports

The anthrax verdict - Case Reports

The anthrax verdict

So what is the verdict on clinical assessment tools used to help diagnose anthrax? Judging from the evidence above, without a known case of anthrax or a good reason to suspect it (such as an alert by the federal government or the CDC), there are no good clinical markers to identify anthrax. But when a case of anthrax is reported in your area or a high alert for bioterrorism exists, anthrax is a legitimate diagnosis. In these cases, findings suggestive of infection include chest films with a wide mediastinum or pleural effusion, altered mental status, and gastrointestinal symptoms. However, even these findings may be of limited diagnostic value.

rash CASE #1

A 15-year-old boy presents to the emergency department complaining of a fever for one day and lesions on his back and trunk that have grown worse over the last three days. The lesions are vesicular, at different stages of development, and have spread to his extremities, with very few on the palms and soles (see image below). The patient does not appear particularly toxic.

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Case #1. This patient actually had chicken pox. Using the risk stratification method described above, the patient had no major and one minor criteria—rash on the palms and soles. He had no febrile prodrome, the lesions were in different stages of development, and they did not have the characteristic morphology of smallpox lesions. Also, the vesicles were centrally distributed and spread rapidly. Last, the patient did not appear toxic. He would be classified as low risk for smallpox with only one minor criterion.
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rash CASE #2

A 10-year-old boy presents to the emergency department after several days of fever and malaise. He developed vesicular lesions on his face and extremities, which spread to his trunk, as well as many lesions on the palms and soles (see image below). He appears toxic.

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Case #2. This patient had smallpox and demonstrated all three major and all five minor criteria. The presence of three major criteria classifies him as high risk for smallpox, regardless of how many minor criteria are present. This patient would require isolation with notification of appropriate consultants and authorities.


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rash CASE #3

A 27-year-old man presents to the emergency department with a fever of one day’s duration and vesicular lesions that started on his face and spread to his chest. All of the lesions evolved at approximately the same rate and did not spread to the extremities (see image below). The patient does not appear toxic.

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Case #3. Herpes simplex is the diagnosis for this patient, who exhibits one major and one minor criterion. The lesions are in the same stage of development and the first ones appeared on the face. He would be classified as low risk for smallpox, because he has one major and less than four minor criteria and does not have a febrile prodrome.


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rash CASE #4

A 42-year-old woman presents to the emergency department after two days of fever and body aches. She developed vesicular lesions on her face, which subsequently spread to her extremities. The lesions are pruritic, do not appear on the palms and soles, and are at different stages of development (see images below). She does not appear toxic.

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Case #4. The rash exhibited by this patient is erythema multiforme. She has no major and two minor criteria. The lesions first started on the face and are centrifugally distributed. She would be classified as low risk for smallpox.

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rash CASE #5

A 28-year-old woman presents to the emergency department with three days of fever to 101.5°F associated with sore throat, enlarged lymph nodes, and fatigue. She developed vesicular and pustular lesions on her hands that spread to her scalp, perineum, extremities, and chest, sparing the palms and soles. All lesions are in the same stage of development (see image below). The patient does not appear toxic.

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Case #5. This patient was infected with monkeypox and has one major and three minor criteria. The lesions were in the same stages of development, centrifugally distributed, slow to progress, and started on the forearm. While the patient was febrile, she was not toxic and so did not meet the definition of the febrile prodrome. One could argue that the lesions were classic smallpox pustules. If so, this patient would have two major criteria and might qualify as moderate risk. However, with no febrile prodrome and so few pustules present, this risk assessment is incorrect. This patient should actually be classified as low risk.

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