title: Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States.
abstract: From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported.
authors.affiliation: NCID, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. jjernigan@cdc.gov
authors.forename: J A
authors.initials: JA
authors.lastname: Jernigan
authors.forename: D S
authors.initials: DS
authors.lastname: Stephens
authors.forename: D A
authors.initials: DA
authors.lastname: Ashford
authors.forename: C
authors.initials: C
authors.lastname: Omenaca
authors.forename: M S
authors.initials: MS
authors.lastname: Topiel
authors.forename: M
authors.initials: M
authors.lastname: Galbraith
authors.forename: M
authors.initials: M
authors.lastname: Tapper
authors.forename: T L
authors.initials: TL
authors.lastname: Fisk
authors.forename: S
authors.initials: S
authors.lastname: Zaki
authors.forename: T
authors.initials: T
authors.lastname: Popovic
authors.forename: R F
authors.initials: RF
authors.lastname: Meyer
authors.forename: C P
authors.initials: CP
authors.lastname: Quinn
authors.forename: S A
authors.initials: SA
authors.lastname: Harper
authors.forename: S K
authors.initials: SK
authors.lastname: Fridkin
authors.forename: J J
authors.initials: JJ
authors.lastname: Sejvar
authors.forename: C W
authors.initials: CW
authors.lastname: Shepard
authors.forename: M
authors.initials: M
authors.lastname: McConnell
authors.forename: J
authors.initials: J
authors.lastname: Guarner
authors.forename: W J
authors.initials: WJ
authors.lastname: Shieh
authors.forename: J M
authors.initials: JM
authors.lastname: Malecki
authors.forename: J L
authors.initials: JL
authors.lastname: Gerberding
authors.forename: J M
authors.initials: JM
authors.lastname: Hughes
authors.forename: B A
authors.initials: BA
authors.lastname: Perkins
mesh_terms: D000328:Adult; D000368:Aged; D000881:Anthrax / Q000453:epidemiology / Q000503:physiopathology* / Q000635:transmission; D001408:Bacillus anthracis / Q000502:physiology; D023482:Bioterrorism; D005260:Female; D006801:Humans; D019570:Inhalation Exposure / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D014481:United States / Q000453:epidemiology