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one of the most viable potential biological weapons due to the stability of anthrax spores, the relative ease of
their dissemination and the high lethality of the disease (see ID: Anthrax).
Subjective: Symptoms
Classic inhalational anthrax follows a “biphasic” course, with a brief period of early non-specific flu-like
symptoms: fever, malaise, fatigue, muscle aches, headaches, mild chest discomfort and non-productive cough.
Following these symptoms patients may experience a partial recovery. However, 1-2 days later, in the final
stage of the disease, patients complain of high fever and significant shortness of breath.
Objective: Signs
Using Basic Tools: Early: Fever, tachypnea; Late: fever, tachycardia, tachypnea, dyspnea, cyanosis,
diaphoresis, hypotension, chest wall edema, meningismus, hemorrhagic mediastinitis, sepsis.
Using Advanced Tools: CXR: Chest x-rays will often demonstrate pleural effusions and widening of the
mediastinum late in the course of the disease. The lung fields themselves may be relatively clear, allowing
differentiation of anthrax from most forms of pneumonia. Early in the disease, chest x-rays may be normal.
Lab: Gram-stain of blood; blood cultures
Assessment:
Differential diagnosis - pneumonia (from either conventional etiologies or other potential biological
weapons: plague, tularemia, staphylococcal enterotoxins), gram-negative sepsis.
Plan:
Treatment: The prognosis for symptomatic anthrax victims is very poor; in all likelihood, 85% or more of
symptomatic victims will succumb even in the face of appropriate therapy. However, EARLY treatment may be
lifesaving.
Primary: Ciprofloxacin 400 mg IV every 12 hours, oxygen, intravenous fluids, antipyretics.
Alternative: IV doxycycline, tetracycline, or penicillin G if ciprofloxacin is unavailable.
Primitive: Use oral ciprofloxacin if IV therapy is not possible.
Patient Education
General: Caregivers need only use standard precautions when dealing with patients since inhalational
anthrax is not contagious.
Prevention: Immunization is an effective preventive measure against anthrax. Consider empiric therapy as
soon as anthrax is suspected. Start asymptomatic persons thought to have been exposed to aerosolized
anthrax on oral ciprofloxacin (500 mg po q 12 hours). Oral doxycycline (100 mg 12 hours) is an acceptable
substitute. Other fluoroquinolones, tetracycline, or penicillin V are alternates. In addition, asymptomatic,
exposed persons who have not received anthrax vaccine should be immunized with at least three doses of
vaccine: at “time zero”, and at 2 and 4 weeks after the first dose.
Follow-up Actions:
Evacuation/Consultation Criteria: Consult Preventive Medicine early for suspected cases. Evacuate if
stable and likely to tolerate travel.
Biological Agents: Botulism
Introduction: Botulism is caused by exposure to one of seven neurotoxins produced by Clostridium botulinum
and related anaerobic bacteria. It is NOT due to infection with the bacteria, so it cannot be treated with
antibiotics and is not contagious. While botulism might be acquired in a number of ways (consuming
contaminated canned foods, inhalation, and rarely, percutaneous inoculation), it is likely to be encountered in