5-91
tender ulcer with black eschar, edema (can persist) Chronic (>2 weeks): Eschar loosens and separates
Pulmonary anthrax: Rapid respiratory rate; neck and chest edema
Gastrointestinal anthrax: Acute(< 1 week): Edema of oropharyngeal tissues Sub acute (1-2 weeks):
Oropharyngeal/tonsillar ulcers; may see bloody ascites
Auscultation: Pulmonary anthrax: Rhonchi or rales; hypotension
Palpation: Cutaneous anthrax: Acute(< 1 week): Regional adenopathy
Pulmonary anthrax: Neck and chest edema
Gastrointestinal anthrax: Tender abdomen
Pulmonary: Percussion: localized dullness
Using Advanced Tools: Lab: Boxcar-shaped, gram-positive rods on Gram stain of skin lesion fluid, or
blood/sputum (late in course) (see Color Plates Picture 13).
Assessment:
Differential Diagnosis:
Cutaneous anthrax:
Staphylococcal boil - does not ulcerate or turn blackish; usually pus-filled and painful.
Orf - history of contact with ungulate’s udders, mucous membranes; lesion can resemble anthrax but does
not blacken.
Scrub typhus - “tache noire” lesion is blackish; usually patient is febrile, often with a generalized petechial
rash.
Spider bite - brown recluse spider bite turns blackish with necrotic changes; usually painful lesion.
Cutaneous plague and tularemia - usually more vivid, painful skin lesions.
Pulmonary anthrax:
Influenza - initial symptoms are similar, but no hemorrhagic mediastinitis or death within 24 hours of onset.
Mediastinitis - usually seen post-operatively (thoracic surgery), with histoplasmosis or after esophageal
perforation.
Gastrointestinal anthrax:
Severe gastroenteritis - early similar symptoms, but no progression to hematemesis, bloody stools,
occasionally bloody ascites, shock and frequent death in 2-5 days.
Plan:
Treatment: Even if left untreated, 80% of cutaneous anthrax remains localized. However, 20% of skin cases
and all other forms of anthrax may die from untreated infection.
Primary:
Cutaneous: Penicillin V 30 mg/kg in four doses/day x 5-7 days and Cipro 750 mg bid for 60 days
Pulmonary: Ciprofloxacin IV 400 mg q12hours x 7-10 days
Gastrointestinal: Ciprofloxacin 750 mg po bid x 60 days
Alternative:
Cutaneous: Levofloxacin 500 mg po q d x 60 days
Pulmonary/Gastrointestinal: Doxycycline 100 mg q12hour or penicillin G 4 MU q4hours IV for 7-10 days
Empiric (presumed exposure):
Pulmonary: Ciprofloxacin 500 mg po bid for 6 weeks, and vaccination
Patient Education
Prevention and Hygiene: A licensed vaccine is available for humans and animals. Human quarantine is
unnecessary, as person-to-person transmission of any form is rare. Use body fluid precautions for duration
of pulmonary and gastrointestinal illness. No viable organisms will remain in skin lesion after 24 hours
of antibiotic therapy. Disinfect premises with 5% formaldehyde and incinerate wound dressings. Incinerate
carcasses or bury deeply and cover with quicklime.