title: Identifying Meningitis During an Anthrax Mass Casualty Incident: Systematic Review of Systemic Anthrax Since 1880.
abstract: Bacillus anthracis, the causative agent of anthrax, is a potential bioterrorism agent. Anthrax meningitis is a common manifestation of B. anthracis infection, has high mortality, and requires more aggressive treatment than anthrax without meningitis. Its rapid identification and treatment are essential for successful management of an anthrax mass casualty incident.
  
  
  
  Three hundred six published reports from 1880 through 2013 met predefined inclusion criteria. We calculated descriptive statistics for abstracted cases and conducted multivariable regression on separate derivation and validation cohorts to identify clinical diagnostic and prognostic factors for anthrax meningitis.
  
  
  
  One hundred thirty-two of 363 (36%) cases with systemic anthrax met anthrax meningitis criteria. Severe headache, altered mental status, meningeal signs, and other neurological signs at presentation independently predicted meningitis in the derivation cohort and were tested as a 4-item assessment tool for use during anthrax mass casualty incidents. Presence of any 1 factor on admission had a sensitivity for finding anthrax meningitis of 89% (83%) in the adult (pediatric) validation cohorts. Anthrax meningitis was unlikely in the absence of any of these signs or symptoms (likelihood ratio [LR]- = 0.12 [0.19] for adult [pediatric] cohorts), while presence of 2 or more made meningitis very likely (LR+ = 26.5 [30.0]). Survival of anthrax meningitis was predicted by treatment with a bactericidal agent (P = .005) and use of multiple antimicrobials (P = .01).
  
  
  
  We developed an evidence-based assessment tool for screening patients for meningitis during an anthrax mass casualty incident. Its use could improve both patient outcomes and resource allocation in such an event.
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Stefan
authors.initials: S
authors.lastname: Katharios-Lanwermeyer
authors.affiliation: Pulmonary, Critical Care and Sleep Medicine Section, VA Palo Alto Healthcare System Department of Medicine, Stanford University, California.
authors.forename: Jon-Erik
authors.initials: JE
authors.lastname: Holty
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Marissa
authors.initials: M
authors.lastname: Person
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: James
authors.initials: J
authors.lastname: Sejvar
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Dana
authors.initials: D
authors.lastname: Haberling
authors.affiliation: Division of Preparedness and Emerging Infections.
authors.forename: Heather
authors.initials: H
authors.lastname: Tubbs
authors.affiliation: National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Dana
authors.initials: D
authors.lastname: Meaney-Delman
authors.affiliation: Division of Preparedness and Emerging Infections.
authors.forename: Satish K
authors.initials: SK
authors.lastname: Pillai
authors.affiliation: Departments of Healthcare Policy and Research and of Medicine, Weill Medical College, Cornell University, New York Presbyterian Hospital, New York.
authors.forename: Nathaniel
authors.initials: N
authors.lastname: Hupert
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: William A
authors.initials: WA
authors.lastname: Bower
authors.affiliation: Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Katherine
authors.initials: K
authors.lastname: Hendricks
mesh_terms: D000293:Adolescent; D000328:Adult; D000881:Anthrax / Q000175:diagnosis* / Q000453:epidemiology* / Q000382:microbiology / Q000503:physiopathology; D001408:Bacillus anthracis; D023482:Bioterrorism; D002648:Child; D002675:Child, Preschool; D060825:Cognitive Dysfunction; D005260:Female; D006261:Headache; D006801:Humans; D008297:Male; D054527:Mass Casualty Incidents; D016920:Meningitis, Bacterial / Q000175:diagnosis* / Q000453:epidemiology* / Q000382:microbiology / Q000503:physiopathology; D008875:Middle Aged
keywords: Bacillus anthracis; anthrax; mass casualty incident; meningitis; resource allocation