* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Cutaneous Anthrax - UNC School of Medicine
Plague (disease) wikipedia , lookup
Brucellosis wikipedia , lookup
Typhoid fever wikipedia , lookup
Rocky Mountain spotted fever wikipedia , lookup
Schistosomiasis wikipedia , lookup
Middle East respiratory syndrome wikipedia , lookup
African trypanosomiasis wikipedia , lookup
Onchocerciasis wikipedia , lookup
Visceral leishmaniasis wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Eradication of infectious diseases wikipedia , lookup
Leptospirosis wikipedia , lookup
1984 Rajneeshee bioterror attack wikipedia , lookup
History of smallpox wikipedia , lookup
Fort Detrick wikipedia , lookup
United States biological defense program wikipedia , lookup
Leishmaniasis wikipedia , lookup
Biological warfare wikipedia , lookup
Bioterrorism wikipedia , lookup
History of biological warfare wikipedia , lookup
Cutaneous Signs of Bioterror Agents Adam Goldstein, MD, MPH Associate Professor UNC Department of Family Medicine Chapel Hill, NC [email protected] Objectives Improve ability to: diagnose and manage cutaneous illness associated with suspected cases of bioterror Anthrax, plague, tularemia, smallpox, mustard gas Why worry? “Subnational attacks using genetically engineered organisms are inevitable” “Biologic agents now join nuclear agents” Deaths 1 KT H-BOMB .6M – 2M 100 Kg ATX 1M – 3M (Stansfield Turner, CIA, 2001) Anthrax Anthrakos = ‘coal’ b/c of black eschar B. anthracis is gram-positive sporulating bacillus Spores are resistant to heat, cold, drying, & chemical disinfection Anthrax is endemic in western Asia (Iran Turkey Afghanistan,) & western Africa (McGovern, Elect Text Dermatol, 1999) Anthrax Spores viable for years top 6 cm of soil & in animal products Disease transmitted from infected animals or products via skin abrasions > 90% of cases Goats > sheep > cattle > horses > pigs > dogs Anthrax Burn dead animals, not buried, to prevent long-term environmental contamination History of Anthrax 1500 B.C. -- Fifth/sixth Egyptian plagues, ? Anthrax 1600s -- "Black Bane," ? anthrax, kills 60,000 cattle 1876 -- Koch confirms bacterial origin of anthrax 1880 -- Immunization of livestock against anthrax 1915 -- German agents in U.S. inject horses/cattle with anthrax on way to Europe during WW I 1937 -- Japan starts biological warfare program 1942 -- Britain experiments with anthrax 1943 -- U.S. begins developing anthrax weapons 1945 -- Anthrax outbreak in Iran kills 1 million sheep Historical 1950s and '60s -- U.S. biological program continues 1969 -- Nixon ends U.S. offensive biological program. 1970 -- Anthrax vaccine approved by U.S. FDA 1972 -- International convention outlaws development or stockpiling of biological weapons 1978-80 -- Human anthrax epidemic strikes Zimbabwe, infecting > 6,000 and killing 100 1979 -- Aerosolized anthrax spores released at Soviet military facility, killing 68 1991 -- U.S. troops vaccinated for Gulf War I 1990-93 -- Terrorists release anthrax in Tokyo; no injuries Historical 1995 -- Iraq produced concentrated anthrax in biological weapons program 1998 -- U.S. approves anthrax vaccinations for all military 2001 -- Letter with anthrax spores mailed to NBC one week after 9/11 terrorist attacks on Pentagon & WTC. Several die after inhaling. Anthrax pilot plant used to produce billions of anthrax spores at Fort Detrick, Md. U.S. ended offensive biological weapons research in 1969 Al Hakam, Iraq's major facility for production of biological agents. Plant destroyed by Iraqi workers in 1996. Forms of Anthrax Pulmonary Anthrax Wool-sorter’s disease 18 cases reported in U.S. 1900-1980 Symptoms: vague prodrome with fever, malaise, myalgias and cough Within days- rapidly developing precordial discomfort, cyanosis, stridor, diaphoresis, moist rales, pleural effusion and death Pulmonary Anthrax X-ray findings: hemorrhagic mediastinitis, but not true pneumonia; widened mediastinum X-ray findings Cutaneous Anthrax Incubation period 7 days (1-12 range) 1) Initial painless papule (head, neck, extremity) • May resemble spider bite and may itch • Surrounding erythema & edema 2) Vesicle or bulla rapidly evolves 3) Painless hemorrhage & necrosis • Fluid becomes black • Lesion ulcerates & develops black eschar with surrounding edema • Pearl-like satellite vesicles may occur Cutaneous Anthrax Lesions progress from: papule - erythema - vesicle - necrosis - ulcer - eschar with or without antibiotic therapy progression d/t toxin Lesions may be solitary or multiple (same part of body) Occasionally associated: Tender lymphadenopathy Fatigue Fever and/or chills (Caruscci, JAAD 2001) Cutaneous Anthrax - Painless Lesions Surrounding edema or regional lymphadenopathy may be painful. Debridement of skin lesions not indicated b/c risk of spreading infection Cutaneous Anthrax Cutaneous Anthrax- painless papule Cutaneous Anthrax- vesicle with edema Cutaneous Anthrax- early necrosis Cutaneous Anthrax- eschar Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax Cutaneous Anthrax: Diagnosis Notify local Health Department Before doing diagnostic tests Mask not required & personnel not at risk Disease acquired through contact with spores, not active bacteria Diagnosis Swab exudates for Gram stain & culture (fresh vesicles) 4-mm punch biopsy full-thickness (through entire dermis) permanent sections immunohistochemistry studies polymerase chain reaction (PCR) A second punch biopsy for Gram stain, bacterial, fungal & atypical mycobacterial cultures Send clinical history (& lesion picture if possible) Negative bx does not r/o cut. anthrax b/c skin lesions caused by toxins Diagnosis Draw 5 mL of blood in red-topped tube Transfer to laboratory for isolation of serum & subsequent storage at –70°C- label tube: “Anthrax serology. Store serum at –70°C for special pick-up.” Draw 5 mL of blood into a purple-topped tube Refrigerate Hold for pick-up- PCR diagnostic tests by CDC Gram Stain Culture (24-36 hours) Differential Diagnosis: (eschar/ulceration) Pruritic and papular arthropod bites Brown recluse and other spider bites Pustular diseases Antiphospholipid antibody syndrome ulcers Aspergillosis Coumadin or heparin necrosis Ecthyma gangrenosum Cutaneous leishmaniasis Mucormycosis Plague Rickettsial pox Staphylococcal & streptococcal ecthyma Tropical ulcer Tularemia Typhus, scrub and tick Differential Diagnosis: (ulceroglandular) Chancroid Glanders Herpes simplex Cutaneous leishmaniasis Lymphogranuloma venereum Melioidosis Cutaneous nocardiosis Plague Sporotrichosis & other deep fungal diseases Staphylococcal & streptococcal adenitis Tuberculosis Tularemia Treatments http://www.bt.cdc.gov/agent/anthrax/index.asp Treatments If suspected anthrax, begin appropriate tx Tx regimen differs by symptomatology (systemic or localized), location (extremity vs head/neck), edema (extensive or not) If systemic signs, head or neck location, or extensive edema, IV therapy indicated Treatment for cutaneous anthrax patients without systemic symptoms, not located on the head or neck, not with extensive edema, & not in children younger than 2 years Category Adults Initial oral therapy Ciprofloxacin, 500 mg bid or doxycycline, 100 mg bid Duration (days) 60 Children Ciprofloxacin, 15 mg/kg q12h (not to exceed 1 g/d) or doxycycline: >8 y o, >45 kg, 100 mg q12h; all other children, 2.2 mg/kg q12h 60 Pregnant Ciprofloxacin, 500 mg bid (preferred) 60 or doxycycline, 100 mg bid Immunocomp Same 60 Treatment of cutaneous anthrax with systemic symptoms, extensive edema, involving the head or neck, or children < than 2 yo (same as for inhalational anthrax) Category IV therapy Duration (days) Adults Ciprofloxacin, 400 mg q12h, or doxycycline,100 mg q12h, and 1-2 additional agents IV initially, oral when stable, 60 days Children Ciprofloxacin, 10 mg/kg q12h IV initially, oral (not to exceed 1 g/d)| or when stable, 60 days doxycycline: >8 y old and >45 kg, 100 mg q12h; all other, 2.2 mg/kg q12h and 1-2 additional agents Pregnant & Immunocom Same as for nonpregnant and immunocompetent adults & children Same Spider bites: Usually painful Usually painful Bites from spiders of the genus Loxoceles begin as pale ecchymotic lesions that rapidly turn purple. Lesions may ulcerate and develop necrotic centers Borders are irregular, illdefined and without the significant surrounding edema. Spider bites Plague Boubon is Greek for groin Y. Pestis, 200 million deaths in history http://www.emedicine.com/derm/topic905.htm#target11 Plague Gram neg non–spore-forming coccobacillus http://www.emedicine.com/derm/topic905.htm#target11 Plague Tender, erythematous lymphadenopathy Most cases involve bubonic plague Tx with streptomycin, gentamicin, tetracycline & doxycycline Plague In bloodstream causes septicemia Tularemia 6 clinical forms: ulceroglandular, glandular, oropharyngeal or gastrointestinal, typhoidal, septicemic, and pulmonary Sudden onset of: Fever, chills, headache, generalized myalgias and arthralgias Incubation 2-10 days Ulcer generally seen at bite or inoculation site Tularemia Painful, pruritic, ulcer w/ RAISED borders Tularemia Ulceroglandular 80% Tularemia In ‘50s and ‘60s, the U.S. made biologic weapons containing tularemia Streptomycin and tetracyclines are drugs of choice Meliodiosis Whitmore’s disease Infectious disease caused by Burkholderia pseudomallei Endemic in SE Asia and northern Australia Common causative agent of community-acquired septicemia (Tran, Clinical & Experimental Dermatology, 2002) Meliodiosis Glanders An infectious disease caused by bacterium Burkholderia mallei, also called “farcy” Primarily affects horses Cutaneous via cut or scratch in the skin, with ulceration and pus 1-5 days at site No cases in U.S. > 60 years Mustard Gas Odor/taste (mustard, garlic, onion), & color (tan to brown to yellow) Oily liquid is DNA alkylating Absorbed within minutes Symptoms begin 2-24 hours later Skin erythema followed by vesicles Mustard Gas Mustard Gas Eyes develop conjunctivitis Pulmonary symptoms- hoarseness Death rate during World War I: 3% Decontaminate w/ 0.5% hypochlorite (1/10 bleach to water) Smallpox Classic generalized exanthem Latin word for “spotted” referring to raised bumps on the face and body http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp Smallpox Rash, high fever & mortality rate 30% Last natural case Somalia in 1977 Smallpox (Days 3, 5, 7) Smallpox Exanthem from vaccination 1/100,000 Vaccinia rash or outbreak of sores Generalized vaccinia Erythema multiforme http://www.bt.cdc.gov/agent/smallpox/ Smallpox Exanthem from vaccination 1/100,000 Vaccinia rash or outbreak of sores Generalized vaccinia Erythema multiforme Smallpox Exanthem from vaccination 1/100,000 Vaccinia rash or outbreak of sores Generalized vaccinia Erythema multiforme Smallpox From Vaccination 1/50,000 Eczema vaccinatum Progressive vaccinia Postvaccinal encephalitis Smallpox From Vaccination 1/50,000 Eczema vaccinatum Progressive vaccinia Postvaccine encephalitis Monkeypox Virus Monkeypox Virus References Carucci JA, McGovern TW, Norton AS. Cutaneous anthrax management algorithm. J Am Acad Dermatol 2001; online at: http://www.eblue.org/scripts/om.dll/serve?action=searchDB&searchD Bfor=art&artType=fullfree&id=a121613 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. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5042a1.htm Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl J Med 1999;341:815-26. http://content.nejm.org/cgi/content/fall/341/11/815 Inglesby TV, Henderson DA, Bartlett JT, Ascher MS, Eitzen E, Friedlander AM, et al. Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA 1999;281:1735-45. http://jama.amaassn.org/issues/v281n18/ffull/jst80027.html Thank you.