GI Anthrax Diagnosed in New Hampshire Woman, Or What the News Leaves Out

I read this account last night about a woman contracting anthrax (which is rare, but cases have occurred from handling unprocessed imported hides).

From WHDH.com:

STRAFFORD, N.H. — Investigators are trying to determine if a woman who took part in an African drumming circle got anthrax from her drum.

The woman from Strafford, New Hampshire got sick earlier in December, and is now in critical condition in the hospital.

State officials believe she may have breathed in anthrax spores, which can occur naturally in animal hides. Officials are asking anyone who attended drumming events at the Waysmeet Center between October and December to contact them.

She breathed in anthrax spores? That would mean that she has inhalational anthrax, right?

From BostonHerald.com:

CONCORD, N.H. — State and federal authorities are searching for the naturally occurring (Editor’s note: Naturally occurring? Says who?) source of anthrax that has left a New Hampshire woman in critical condition.

State public health director Dr. Jose Montero says the woman from Strafford County became ill in early December. Authorities have confirmed she is suffering from gastrointestinal anthrax and are investigating whether the anthrax spore came from an African drum she took to a drum circle event at the United Campus Ministry at the University of New Hampshire.

Montero says investigators are testing the drums because two recent anthrax cases in New York and Connecticut were related to animal hides. He says anthrax is not transmitted from person to person and the public is not at risk

Hunh. She clearly didn’t “breathe in” spores that caused her case of GI anthrax.

Disease from exposure to anthrax spores comes in three forms: Cutaneous anthrax (from spores entering the skin through a cut), inhalation anthrax (inhaling the spores), and intestinal anthrax (swallowing the spores in undercooked meat from diseased animals). Unless she was chewing on the drum or had recently been out of the country into an area where anthrax is endemic and eaten diseased, undercooked meat contaminated by anthrax spores, I have to wonder about the etiology of this. I also have to wonder about the sloppy reporting that gives the impression that inhaling spores causes GI/intestinal anthrax.

Per the CDC:

While the biowarfare and bioterrorist development of anthrax has focused on inhalation, ingestion has been considered as well. The Japanese experiments in China during the 1930s and 1940s included attempts to poison children with chocolate impregnated with anthrax (31). More recently, the apartheid government of South Africa had developed biological weapons, including another attempt at anthrax-containing chocolate (32). Given the large community outbreak of salmonellosis caused by an intentional contamination of restaurant salad bars the in United States by the Rajneeshees (33), awareness of the potential for GI anthrax due to bioterrorism is important.

In conclusion, GI anthrax is probably greatly underreported in rural disease-endemic areas of the world. The spectrum of disease, ranging from no symptoms to death, has not been fully appreciated. Awareness of anthrax in a differential diagnosis remains important in disease-endemic areas and also in settings of possible bioterrorism.

So, GI anthrax is rather rare even in rural disease-endemic areas of the world (where it may be underreported) and, when it appears outside those areas, we need to consider bioterrorism. Just how rare is it?

BACKGROUND: Bacillus Anthraces is a non-motile, rod like, gram-positive and aerobic bacillus that produces central oval-shaped spores and characterized by rough, irregular and often comma-shaped colonies in blood agar. About 95% of human anthrax is cutaneous and 5% respiratory. GI anthrax, a very rare type, has been reported in less than 1% of all cases. We thus report a case of GI anthrax with autopsy findings. CASE REPORT: A 15-year-old young adult man was admitted to our hospital with history of fever, abdominal pain and bloody diarrhea from 48 hours after ingestion of half-cooked sheep’s meat. In endoscopic exam of upper GI tract, the esophagus had been filled with fresh blood without any varices, stomach showed evidence of hemorrhage and had multiple erosion but no ulceration of duodenum. Penicillin G 24,000,000 U/day IV was started but unfortunately severe upper and lower GI hemorrhage developed, leading to hypotension and death. In autopsy, ascites, paraaortic and mesenteric lymphadenopathy was accident with some of them being hemorrhagic. The spleen was slightly enlarged with hemorrhagic congestion in some parts of it. In the blood sample drawn from the spleen, the filamentous bacillus was successfully found. CONCLUSIONS: Because of the fatal nature of the disease and the similarity of the signs and symptoms to the other gastrointestinal diseases, we should consider it as one of the probable differential diagnosis in the patients with upper and lower gastrointestinal bleeding with fever esp. in the endemic areas.

Less than 1% of anthrax cases are GI? Very rare indeed. The case listed just above became ill just 48 hours after ingestion? I suppose that would vary from person to person with the amount of infection present in the meat/spore count. The CDC, in investigating cases of GI anthrax in Thailand, found a mean time between ingestion and symptoms of @ 42 hours. Children in Africa that ingested undercooked contaminated meat in another case perished in @ 24 hours after ingestion.

So, how big of a risk could drums really pose for contracting GI anthrax? Not much, unless she ate the drum.

How is anthrax transmitted?
B. anthracis spores can live in the soil for many years, and humans can become infected with anthrax by handling products from infected animals or by inhaling anthrax spores from contaminated animal products. Anthrax can also be spread by eating undercooked meat from infected animals. It is rare to find infected animals in the United States .

Am I at risk for anthrax from animal hides or hair, or from making a drum from these products?
Animal hides pose a low risk of cutaneous (skin) anthrax, and an extremely low risk of inhalation anthrax. Exotic animal hides may pose a higher risk for exposure than domestic (U.S.-origin) hides. The risk of contracting Bacillus anthracis from handling individual hides is believed to be very low; however, the industrial processing of hides or hair has historically been associated with increased risk of anthrax. Such industrial handling of large numbers of hides or hair from multiple animals results in prolonged direct contact with contaminated materials, often in enclosed or poorly ventilated settings. Among the 236 cases of anthrax reported to CDC from 1955 to 1999, 153 (65%) were associated with industrial handling of animal hide or hair. Only 9 of the 153 cases (6%) associated with industrial handling of hair or hide were inhalation anthrax. (Editor’s note: Apparently none of those cases were GI anthrax.)

Am I at risk for anthrax from my souvenir animal hide drum?
The risk of acquiring anthrax from an animal hide drum is very low. Of 236 cases of anthrax reported to CDC from 1955 through 1999, only one case of cutaneous anthrax was associated with a goat hide bongo drum purchased in Haiti . No cases of inhalation anthrax in the US have ever been associated with animal hide drums. The New York patient’s exposure occurred when he was making and finishing drums made from untanned animal hides, and was not associated with playing finished drums. His exposure was similar to that experienced during industrial handling of hides, which has previously been associated with an increased risk of anthrax. CDC does not currently recommend prophylaxis for persons who have had contact with animal hide drums. However, drum owners or players should report any unexplained fever or new skin lesions to their healthcare provider, and describe their recent contact with animal hide drums.

Recent cases of anthrax in USA related to importing untanned hides from Africa for drums (September 2007).

Mayor Mark D. Boughton of Danbury said the house was being used to store untanned animal hides obtained from areas of the world where anthrax is known to be common.

At least one of the patients is believed to have contracted cutaneous anthrax from working with the hides, Mayor Boughton said. Local and state officials were examining the patient’s house in an effort to pinpoint the source of the anthrax, Mayor Boughton said.

It is the second time in two years that African drummers in the metropolitan region have contracted anthrax.

In both cases, untanned hides for drums were believed to be the source.

These cases were cutaneous anthrax.

To recap: It would appear that if the woman got anthrax from banging on a drum, it would be either cutaneous or inhalation anthrax. No cases of GI anthrax from drum banging has been reported. The most commonly contracted form of anthrax, cutaneous anthrax, was acquired from drumming. People working with/storing hides have come down with inhalational anthrax. Let’s review those causes of anthrax again:

In humans there are three possible forms of the disease anthrax. Historically, the most common form has been cutaneous anthrax, in which the organism enters through a break in the skin. The cutaneous form begins as a papule at the entry site that progresses over several days to a vesicle and then ulcerates. Edema, sometimes massive, surrounds the lesions, which then develop a characteristic black eschar. The patient may have fever, malaise and headache.4 A small percentage of cutaneous infections become systemic, and these can be fatal.

A more serious form is inhalation anthrax. Here the victim breathes in the organism and develops a severe respiratory disease. Systemic infection resulting from inhalation of Bacillus anthracis has a mortality rate approaching 100%. Initial symptoms are vague and flu-like, progressing to hypotension, shock and massive bacteremia and toxemia. The severe symptoms are believed to be the result of the bacillis exotoxins. Early antibiotic treatment is an absolute necessity and should be started during the incubation period if a person has been exposed.5 After acute symptoms have appeared, antibiotics can kill the organisms, but will not destroy the powerful toxins that have already been formed, and the person commonly dies in 2-3 days from respiratory failure, sepsis and shock.

The third form, intestinal anthrax, is contracted from the consumption of contaminated meat. In industrialized countries this is not usually a risk, although rare exceptions have been described. In August 2000, the Minnesota Department of Health was notified that Bacillus anthracis had been isolated from a steer on a farm in Roseau County. The infected steer was one of five dead cattle found in a pasture. On the basis of identification of the bacteria by phage typing of isolates cultured from tissues and blood samples by the North Dakota State University Veterinary Diagnostic Laboratory, anthrax was confirmed. A report of this incident described the management of and public health response to human exposure to meat contaminated with anthrax.

So, instead of chasing drums, shouldn’t the question be “where did this woman eat anthrax-contaminated meat”? If she didn’t eat anthrax-contaminated meat, where did she acquire this disease? Until such time as the source of anthrax-infected meat is identified, this should be presumed to be bioterrorism. It should also be presumed that there are/will be more cases unless she was in an anthrax-endemic country shortly before becoming ill or ingested undercooked meat originating from said anthrax-endemic country. I certainly hope that hospitals/physicians have been alerted to BOLO for additional cases.

If you work with untreated hides imported from anthrax endemic countries, do yourself a favor and get the anthrax vaccine.

Update:

Concord – Two African drums stored at the University of New Hampshire United Campus Ministry have tested positive for anthrax, public health investigators confirmed today.

The young woman with gastrointestinal anthrax who attended a drum circle at the Durham center remains in critical condition, state Public Health Director Jose Montero said.

The state has closed the Campus Ministry, which is unaffiliated with the university, continues to test drums and is asking drum owners who attended the events to call in for possible testing.

Montero said the state lab has sent some samples, including DNA samples, for further testing at the U.S. Centers for Disease Control.

About a half dozen attendees have contacted the state health officials, when more than 50 people may have attended the most recent drum circle. Thirty or more drums were stored at the Durham building.

Montero said the unidentified Strafford County woman brought her own drum, which was a synthetic drum, and not one of goat animal skin used in a typical West African drum.
Investigators are probing other possible sources of contamination, including soil, drug and food the woman may have ingested.

1. Her drum was made of synthetic materials.
2. Two African drums stored at the University where the drum circle took place tested positive for anthrax spores (if drums are made of hides imported from Africa or Haiti that are haired or untanned, they have a pretty good likelihood for being positive for anthrax, something that the immunocompromised should be aware of but probably are not).
3. Other people that were at the drumming circle (last month!) are being given antibiotic prophylaxis, although none have showed any symptoms.
4. The mean time between ingestion and symptom onset is @ 42 hours with a variation of 1 to 7 days. The longer periods of time between exposure and symptoms are for inhalation anthrax.

I agree with the antibiotic prophylaxis for the people at the drum circle because it can take 60 days from exposure for pulmonary anthrax to manifest, although people that have contracted pulmonary anthrax from drums were making drums and/or had multiple anthrax-spore-infested hides on the premises, and were exposed to a much higher spore count than what the average drummer/participant would be subject to. While the chance of infection from such an event is *very* low, the fatality rate is very high, and the prophylaxis is inexpensive.

I still wonder how it is that this woman (with the synthetic drum) is the only person that became ill. Did she (or anybody else) have an open drink at the event? Were anthrax-spore-covered cookies served afterwards? If so, how is it that only her drink/food were sufficiently covered in spores so as to cause illness?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: