It is the goal of this Literature
Review to outline the summary of the Article “Bioterrorism-related inhalational
anthrax: the first 10 cases reported in the United States” (2001) by John A.
Jernigan, et al,. This will be conducted in order to achieve a better
understanding of the function of the disease and to take a look at the actual
field examples of the illness. I will examine and summarize the factors most
important to the disease that I feel are pertinent based on the criteria beset
within the patient at the time of illness. I will discuss three out of the 10
cases presented in the study.
This case study looks to examine,
individually, 10 separate cases (rightly the 10 first cases) of inhalational
anthrax due to bioterrorism in the U.S. The method of dispersal for these
agents was found to be in the form of powdered Bacillus anthracis. Of the 10 cases, 7 were seen in the employees
of the postal service. The geographic distribution found that patients were
spread across New Jersey, the District of Columbia, Florida and New York. B. anthracis is able to be the
determined the causative agent through gamma phage lysis, capsule confirmation,
cell-wall antigens and a specific B.
anthracis polymerase chain reaction. The most identifiable test is the PCR
test in which the genetic material for the B. anthracis is compiled and
analyzed to provide a template for identification. This is known as a BLAST
nucleotide test.
Case #1
The initial case (#1) had an
apparent onset on October 2, 2011. It was a 63-year-old Caucasian male who
worked at a Florida newspaper. His symptoms were nausea, vomiting, and
confusion. Prior to this he was feeling ill on September 27 during a trip to
North Carolina. The symptoms of the initial illness were characterized by
malaise, fatigue, fever, chills, and sweats. It is important to note that with
this case there was no history of a headache, cough, chest pain, dyspnea,
diarrhea, or skin lesions.
Treatment:
Day 1: He reported to the hospital not oriented to person place or
time. While he did not report chest pain or other symptoms indicative of a
pleural edema, when the chest x-ray did come back it showed a prominent
superior mediastinum and small left pleural effusion. The hospital diagnosis of
the anthrax did not come until they looked at the cerebrospinal fluid (CSF).
They were able to isolate B. anthracis from CSF after 7 hours of
incubation. During day one, a full diagnosis of meningitis and antibiotic
treatment ensued. After admission on day 1 he began to have seizures and was
intubated for airway protection.
Day 2: Penicillin G, levofloxacin, and clindamycin were
administered and previous antibiotic treatments were halted. The patient’s
condition deteriorated as renal failure began. The patient died on October 5.
The cause of death was hemorrhagic mediastinal lymphadenitis because the B.
anthracis had spread throughout his body.
Summary: On Oct 2, PT was
taken to emergency room. PT had an onset of initial symptoms on Sep27. Day one
of the hospital showed treatment with multiple wide spectrum antibiotics on OCT
2. Day two of hospital treatment saw additional antibiotic treatment and
witnessed more rapid patient deterioration on Oct 3. On Oct 5th, the
patient died and the bacteria were found to be in multiple organs. This case
shows the short potential incubation period of the disease and how quickly an
infection is able to desaturate a patient.
Case #4:
On October 16, a 56 y/o
African-American male postal worker noted a constant mild headache. Over the
time of three days the headache became more prominent and was now accompanied
by a low grade fever, chills, sore throat, nausea , photophobia(light
sensitivity), and blurred vision. These neurological symptoms were accompanied
with difficulty breathing, a dry cough, and chest pain.
Treatment:
Day 1: On October 20, the Pt reported to the hospital as afebrile (without
his fever) and with decreased breath sounds. Blood draws were shown to contain
an increase in bilirubin and hepatic enzymes, low albumin, and hypoxia. It is
reported that no organisms were seen on Gram stain of the patient’s
Cerebrospinal fluid and the CSF culture did not gro. A chest X-ray showed
pleural effusions and diffuse mediastinal edema. The confirmation of B. anthracis
was made when blood cultures grew the bacteria within 15 hours of admission to
the hospital. Antibiotic treatment immediately ensued and included
Ciprofloxacin, rifampin, and clindamycin.
Day 3: On October 22, worsening respiratory distress was noted
Day 4: on October 23, the patient underwent therapeutic
thoracentesis. This is an attempt to drain the fluid that is inside of the
lungs. After this treatment his condition improved. He was given a second
thoracentesis and given corticosteroids for bronchospasm.
Day 17: Patient is discharged from hospital
Summary: Besides the obvious contrast
with Case #1 that this patient survived, it appears that the treatment with
initial antibiotics and early diagnosis (within one day) of the bacteria was
not enough to halt the complication that the disease caused. In this case it
was combined with interventional therapy in the form of a thoracentesis to
remove the fluid. After sever positive responses with this procedure, the
patient’s status improved greatly.
Case #6:
On October 16, a 47 y/o African- American male postal service
employee who is affiliated with the same work center as case number 4 reported
initial mild cough, nausea, vomiting and stomach cramps. On Oct 20 the patient
passed out at church (syncope) but failed to seek medical treatment.
Treatment:
Day 1: Early on October 21 the
patient checked into an emergency department with a chief complaint of vomiting
and profuse sweating. He had a history of renal complications and asthma. He
did not report with an initial fever. The chest X-ray was initially read as
normal, but late the review had discovered a small margin of an increased density.
The patient was discharged after receiving I.V fluids with no antibiotic
treatment.
Day 2: In the morning of October 22
the patient again returned to the emergency department. He reported with
chills, dyspnea, vomiting and another syncopal episode (fainted). At this point
his blood pressure was 76/48 mm Hg. HR was 152 min and respiratory rate was 32
min. He was in respiratory distress with bilateral wheezing, tachycardia, and a
distended abdomen. At this point a full lab work up revealed an infection and penicillin;
ceftriaxone, rifampin, and levofloxacin were administered. The patient’s respiratory
rate continued to be inhibited and required intubation and mechanical ventilation.
A second X-ray shows mediastinal edema and bilateral pleural effusions. The
patient died within 6 hours of admission. The Gram- positive bacilli were
visible on the buffy coat blood smear and blood cultures grew B. anthracis within 18 hours. Cause of
death was hemorrhagic mediastinal lymphadenitis.
Summary:
We learn from this case that the delay of initial antibiotic treatment and
identification of infection resulted in the increase degradation of the patient
and ultimately resulted in death. This case shows how critical it is to
Conclusion:
Overall this research was very informative about the
mechanisms of action for this type of bacteria. As we hear of forms of
bioterrorism in the world today we need to understand just what it is that is
affecting us. The critical knowledge gained from this study will prove to be
essential for the identification of the disease again because, as in this case,
time is critical. The case studies seen here were compiled forms of the
original study by John A. Jernigan, et al,. (2001). This review was meant to be
a brief educational explanation of what my interpretation of the cases where
and how they affect the prevention and treatment of Anthrax for the future. Due
to the compiled nature of this review much information was omitted. To view the
full study, please click on the following link.
References:
Jernigan, J. A., Stephens, D. S., Ashford, D. A., Omenaca, C., Topiel, M.
S., Galbraith, M., . . . Perkins, B. A. (2001). Bioterrorism-Related
Inhalational Anthrax: The First 10 Cases Reported in the United States. Emerging Infectious Diseases, 7(6), 933-944. doi:10.3201/eid0706.010604
Media References (in order of appearance):
http://science.howstuffworks.com/anthrax2.htm
http://en.wikipedia.org/wiki/Pleural_effusion
http://www.skinsight.com/atlas/anthrax.htm
No comments:
Post a Comment