title: Death due to bioterrorism-related inhalational anthrax: report of 2 patients.
abstract: On October 9, 2001, a letter containing anthrax spores was mailed from New Jersey to Washington, DC. The letter was processed at a major postal facility in Washington, DC, and opened in the Senate's Hart Office Building on October 15. Between October 19 and October 26, there were 5 cases of inhalational anthrax among postal workers who were employed at that major facility or who handled bulk mail originating from that facility. The cases of 2 postal workers who died of inhalational anthrax are reported here. Both patients had nonspecific prodromal illnesses. One patient developed predominantly gastrointestinal symptoms, including nausea, vomiting, and abdominal pain. The other patient had a "flulike" illness associated with myalgias and malaise. Both patients ultimately developed dyspnea, retrosternal chest pressure, and respiratory failure requiring mechanical ventilation. Leukocytosis and hemoconcentration were noted in both cases prior to death. Both patients had evidence of mediastinitis and extensive pulmonary infiltrates late in their course of illness. The durations of illness were 7 days and 5 days from onset of symptoms to death; both patients died within 24 hours of hospitalization. Without a clinician's high index of suspicion, the diagnosis of inhalational anthrax is difficult during nonspecific prodromal illness. Clinicians have an urgent need for prompt communication of vital epidemiologic information that could focus their diagnostic evaluation. Rapid diagnostic assays to distinguish more common infectious processes from agents of bioterrorism also could improve management strategies.
authors.affiliation: Johns Hopkins Center for Civilian Biodefense Studies, Johns Hopkins University, Candler Bldg, Suite 850, 111 Market Pl, Baltimore, MD 21202, USA. lborio@nih.gov
authors.forename: L
authors.initials: L
authors.lastname: Borio
authors.forename: D
authors.initials: D
authors.lastname: Frank
authors.forename: V
authors.initials: V
authors.lastname: Mani
authors.forename: C
authors.initials: C
authors.lastname: Chiriboga
authors.forename: M
authors.initials: M
authors.lastname: Pollanen
authors.forename: M
authors.initials: M
authors.lastname: Ripple
authors.forename: S
authors.initials: S
authors.lastname: Ali
authors.forename: C
authors.initials: C
authors.lastname: DiAngelo
authors.forename: J
authors.initials: J
authors.lastname: Lee
authors.forename: J
authors.initials: J
authors.lastname: Arden
authors.forename: J
authors.initials: J
authors.lastname: Titus
authors.forename: D
authors.initials: D
authors.lastname: Fowler
authors.forename: T
authors.initials: T
authors.lastname: O'Toole
authors.forename: H
authors.initials: H
authors.lastname: Masur
authors.forename: J
authors.initials: J
authors.lastname: Bartlett
authors.forename: T
authors.initials: T
authors.lastname: Inglesby
mesh_terms: D015746:Abdominal Pain / Q000150:complications; D000881:Anthrax / Q000097:blood / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001408:Bacillus anthracis / Q000302:isolation & purification*; D023482:Bioterrorism; D001769:Blood / Q000382:microbiology; D001919:Bradycardia / Q000209:etiology; D004219:District of Columbia; D004417:Dyspnea / Q000150:complications; D017809:Fatal Outcome; D005334:Fever / Q000150:complications; D006323:Heart Arrest / Q000209:etiology; D006708:Homicide; D006801:Humans; D007964:Leukocytosis; D008297:Male; D008480:Mediastinitis / Q000000981:diagnostic imaging; D008875:Middle Aged; D009325:Nausea / Q000150:complications; D016273:Occupational Exposure; D010996:Pleural Effusion / Q000000981:diagnostic imaging; D011177:Postal Service; D013902:Radiography, Thoracic; D012121:Respiration, Artificial; D012141:Respiratory Tract Infections / Q000097:blood / Q000175:diagnosis / Q000382:microbiology* / Q000503:physiopathology / Q000628:therapy; D013171:Spores, Bacterial / Q000302:isolation & purification*; D013610:Tachycardia / Q000209:etiology; D014057:Tomography, X-Ray Computed
chemical_list: D000900:Anti-Bacterial Agents