Re: Minnesota investigating inhalation anthrax case
http://www.promedmail.org/pls/apex/..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,90074
Archive Number 20110831.2670
Published Date 31-AUG-2011
Subject PRO/AH/EDR> Anthrax - USA (09): (MN)
ANTHRAX - USA (09): (MINNESOTA)
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[1]
Date: Tue 30 Aug 2011
Source: CIDRAP (Center for Infectious Disease Research & Policy) News
[edited]
<http://www.cidrap.umn.edu/cidrap/content/bt/anthrax/news/aug3011anthrax.html>
Early diagnosis and treatment helped Florida man beat anthrax
-------------------------------------------------------------
Early diagnosis and treatment were crucial in helping a Florida man
beat the odds by recovering from inhalational anthrax, a rare and
often deadly disease, according to a Minneapolis physician who treated
him.
The patient, aged 61, of St Petersburg, Florida, was released from
Hennepin County Medical Center (HCMC) in Minneapolis yesterday [29 Aug
2011] after more than 3 weeks of hospitalization, the Minneapolis Star
Tribune reported today. He had somehow contracted the disease during a
3 week vacation in Montana, Wyoming, and the Dakotas, and was sick
when he arrived in Minnesota near the end of the trip.
"I think a key part of his survival was that he was diagnosed
reasonably early ... and got started on the right therapy. If that
hadn't happened it wouldn't have been good," Dr Mark Sprenkle of the
Division of Pulmonary and Critical Care Medicine at HCMC told CIDRAP
News. He also said the use of anthrax immune globulin supplied by the
Centers for Disease Control and Prevention (CDC) may have contributed
to [the man's] recovery.
The Minnesota Department of Health (MDH) first reported the anthrax
case on 9 Aug 2011, but the patient remained unnamed until today's
newspaper story. MDH officials believe [the patient] contracted
anthrax through exposure to _Bacillus anthracis_ spores in the soil in
one of the states he visited. The Federal Bureau of Investigation
investigated the case initially but concluded there was no evidence of
bioterrorism.
[He] was feeling "overtired" when he and his wife arrived in Pelican
Rapids, Minnesota, on 3 Aug 2011 to visit friends, according to the
Star Tribune. By the next day he was very sick and was hospitalized in
Fergus Falls, Minnesota, where he was treated for pneumonia. A doctor
there was alarmed by the appearance of his lung x-ray and ordered a
lab test, which showed an unusual _Bacillus_ strain, the story said.
The doctor then sent a sample to the MDH, which confirmed the presence
of _B. anthracis_.
[The patient] was transferred to HCMC by air ambulance on 7 Aug 2011.
When he arrived he was awake and conversant and receiving supplemental
oxygen, but his condition deteriorated within a few hours, and he was
soon transferred to the intensive care unit (ICU), according to
Sprenkle. "By the time he was in the ICU he had pretty severe hypoxia
and respiratory distress and was put on a ventilator," he said.
Doctors in Fergus Falls had initially treated [him] with antibiotics
for bacteria commonly seen in community-acquired pneumonia, but once
the anthrax diagnosis came through, they switched to drugs recommended
for that disease, Sprenkle said. At HCMC the patient was initially
treated with ciprofloxacin and clindamycin, he said.
On his 2nd day at HCMC, [the patient] also was treated with anthrax
immune globulin provided by the CDC, a product derived from the serum
of people who have received the anthrax vaccine, Sprenkle reported.
"It's antibodies that can be administered to people who have active
infection, to bind up the [anthrax] toxin and mitigate the disease,"
he said. Sprenkle said [the patient] was only the 19th person to
receive the human-derived anthrax immune globulin, which he said
wasn't available in 2001 when 22 people contracted anthrax infections
after envelopes containing spores were mailed to media outlets and 2
US senators. The immune globulin was used more recently to treat some
patients in an outbreak of cutaneous anthrax in Scotland, he said. A
supply of human-derived anthrax immune globulin is held in the
Strategic National Stockpile of drugs and medical supplies, CDC
officials said today [30 Aug 2011], but the amount of the supply is
kept secret for security reasons. The product was used successfully to
treat an inhalational anthrax patient under an emergency protocol in
2006, according to a 2007 report in Clinical Infectious Diseases.
By the time the patient was hospitalized at HCMC, his blood cultures
were already negative for _B. anthracis_, but the toxin produced by
the bacterium remains after the infection itself subsides, Sprenkle
noted. [Thus] another part of the treatment was to drain a buildup of
pleural fluid from around his lungs, with the aim of reducing the load
of anthrax toxin in his body, Sprenkle said. Fluid around his right
lung was drained on his 1st day in the hospital, and the other side
was drained the next day.
Sprenkle said it is difficult to pinpoint when [the patient] reached a
turning point, but he commented, "I think after 7 days I began to feel
more confident he was going to be able to get through things." [The
man] remained on the ventilator for 10 to 14 days, however.
The mortality rate for inhalational anthrax is typically listed at 80
per cent to 90 per cent, but that is based largely on old data, such
as an outbreak in Russia in 1979, Sprenkle noted. Mortality in
inhalational cases in the 2001 anthrax attacks was more like 45 per
cent, he said. In any case, the risk was very serious for [this
patient], Sprenkle said, "but there were a lot of things that helped
him. He was diagnosed reasonably early, he was put on the right
antibiotics reasonably early, and we did the pleural drainage and he
received immune globulin."
[The man] will need to continue taking oral ciprofloxacin for several
more weeks, in line with CDC recommendation for 60 days of treatment
in such cases, Sprenkle said. He said his patient may have some
lingering effects for a few weeks or longer, but predicted he will
recover fully in time.
[byline: Robert Roos]
--
communicated by:
ProMED-mail rapporteur Mary Marshall
******
[2]
Date: Tue 30 Aug 2011
Source: Star Tribune [edited]
<http://www.startribune.com/bios/10645281.html>
[The man] and his wife were wrapping up a glorious summer vacation
when they arrived in Pelican Rapids, Minnesota, in early August [2011]
to visit friends. They had just spent 3 weeks on the road, visiting
the great parks of Wyoming, Montana, and the Dakotas. But the [61 year
old man] an active outdoorsman from Florida, was feeling a little
"punky," as he put it. "I was overtired," he said. "That's what I
thought." 2 days later, he was fighting for his life, with a case of
anthrax that triggered a state investigation and brought the FBI to
his hospital room.
On Monday [29 Aug 2011], [he] was released from Hennepin County
Medical Center in Minneapolis, where he was hospitalized for 3 weeks,
much of it in critical condition. Doctors say he survived a rare and
extremely deadly type of anthrax infection, which they assume he
picked up from natural sources on his road trip. His illness prompted
a nationwide alert because anthrax can be used as a terrorist weapon.
And medical experts are still trying to figure out how he managed to
breathe in the deadly spores, which can exist in soil and infected
animals, while doing nothing particularly dangerous. "We were
tourists," said his wife of 36 years. "And now look where we are."
Today [30 Aug 2011], her husband is a little weak and prone to
coughing fits. But otherwise, as he prepares to head home, he says,
"I'm feeling pretty good for what I've been through."
The couple, who live in St Petersburg, had never been to the Upper
Midwest before July 2011, when they flew to Fargo to begin their
long-awaited trip. They rented a car and drove west -- to Yellowstone
and to Wind Cave National Park and Custer State Park in South Dakota.
"All the dirt roads and ponds, we saw it all." [The man], who is
retired from the irrigation business, occasionally picked up garnets
and other rocks to use in making jewelry. The couple drove through a
herd of bison, but got no closer than any other tourists did, he says.
By the time they reached Minnesota on 3 Aug 2011, they'd covered
thousands of miles. He went fishing with his pal the next day. "That's
the last thing I can remember," he said.
At the hospital in nearby Fergus Falls, he was treated for pneumonia.
But Dr Joe Meyer was alarmed by the X-ray: it was unlike any case he'd
ever seen. "I knew that this was going to be something serious," he
said. Meyer sent a specimen to the lab at the hospital, Lake Region
Healthcare; the results showed an uncommon bacillus strain -- the same
family as anthrax. He overnighted a sample to St Paul, and the
Minnesota Department of Health confirmed it.
"It's an extremely rare occurrence," said state epidemiologist Dr Ruth
Lynfield. "It isn't something that one would expect in somebody coming
to their ER." So the staff at Fergus Falls, she said, deserves credit
for acting so quickly. "They knew what they were doing, and they were
able to put the picture together."
[The man] was transferred by air ambulance to HCMC on 7 Aug 2011.
Within hours, "he was on life support," said his wife. A small army of
federal and state investigators came calling. They asked the same
questions: Where had they traveled? How could he have been infected?
The FBI wanted to rule out terrorism, and the agent "was very nice,"
she said. "I'm sure he knew everything there was to know about us
already." Health Department investigators, clad in protective gear,
combed through the rental car, checking the air filters, wheel wells,
souvenirs, everything, for anthrax spores. They found none.
In the meantime, he was getting a series of powerful antibiotics, and
the US Centers for Disease Control and Prevention in Atlanta sent a
special treatment called immunoglobulin, designed to fight the deadly
toxins. Slowly, he started improving, opening his eyes, squeezing his
hands, moving his toes. On 17 Aug 2011, [his daughter's] birthday, he
sang to her. "That," says his wife, "was probably the 1st time that I
really realized things were going to be OK."
By last Friday [26 Aug 2011], [the patient] was sitting up in bed,
eating lunch, and chatting about his ordeal. One of his doctors, he
said, told him that at one point, he had only a 5 per cent chance of
survival. "It was something to hear," he said matter-of-factly.
[The man] has a history of beating the odds. In the Air Force, his
AC-130 gunship was almost shot down over Viet Nam. 11 years ago, he
survived a horrific car crash. And now this. "He's Mister Miracle
Man," said his wife.
Just how he got anthrax -- and why his wife didn't -- is still a
puzzle. "We haven't completed our investigation," said Lynfield, "but
it may yet remain a mystery."
[byline: Mura Lerner]
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[3]
Date: Wed 31 Aug 2011
From: Robert Spencer <Robert.Spencer@UHBristol.nhs.uk> [edited]
[re: Early diagnosis and treatment helped Florida man beat anthrax.
See item [1] above. Mod.MHJ]
Inhalational anthrax
--------------------
As with any serious infection, the sooner the correct diagnosis of
systemic anthrax is made, and appropriate antimicrobial therapy
administered, the better the outcome for the patient. Inhalational
anthrax is often confused, on hospital admission, with community
acquired pneumonia for which antibiotic treatment often includes a
cephalosporin -- the one class of antibiotics known to be inactive
against _Bacillus anthracis_.
This case again shows the worth of the microbiology laboratory in
finding the true cause of his infection. This was also demonstrated in
the inhalation anthrax cases of the New York stilt dancer and the
Hackney [London] bongo drummer. In both instances the blood cultures
became positive very soon after hospital admission. The value of
continuous draining of the pleural effusions, to reduce the toxin
load, is again supported.
The exact role of the human-derived anthrax immune globulin still
remains to be accurately delineated. But if more subsequent cases of
systemic anthrax are given this treatment, then hopefully a clearer
picture of its role in such conditions will emerge.
--
Dr Robert C Spencer
Health Protection Agency
Bristol, England
<Robert.Spencer@UHBristol.nhs.uk>
[Minnesota State epidemiologist Dr Ruth Lynfield said the Fergus Falls
hospital staff deserves credit for acting quickly in the case. "They
knew what they were doing, and they put the picture together," she
said. Amen. If they had not been alert this man would have died. This
is reinforced by Bob Spencer's comments, for which I am grateful; Bob
was closely involved in the Scottish contaminated heroin incident of
last year. (2010).
An important aspect of the treatment of human anthrax cases is the
need for keeping the affected organs drained of the toxin infested
bloody oedematous fluids. The injected immunoglobulin will absorb some
of the toxins but certainly not all and how much this treatment
contributes to the ultimate success is unclear at this time. But one
aspect is clear to this moderator: that the amounts of the various
toxins, even as they are mechanically removed, will "vaccinate" the
patient. This should limit the extended needs claimed for
ciprofloxacin. Various agencies insist it is necessary for 60 days,
which was originally put forward in relation to aerosol exposures and
the dangers of lurking spores in the lung. This man's spores have
germinated in early August 2011, he is abacteraemic, and is probably
now immune. I am not a clinician but I suspect that continued
treatment with ciprofloxacin presents more risks than benefits.
This is a long posting but I wanted the members to appreciate (1) the
need for rapid recognition and early treatment of pneumonic anthrax,
and (2) that this case had a prior chronic lung condition -- presently
undefined -- such that he was affected but his wife not at all, apart
from the stress of the events. The latter incidents are accumulating
and so we can expect, and be prepared, to see more of them. - Mod.MHJ]
