Complicated Cutaneous Anthrax

A 12-year-old girl presented to the emergency department with progressing generalized inflammatory symptoms (fever and malaise), visual difficulty, severe inspiratory dyspnea, and 2 painless lesions on the right upper lip that had persisted for a few days. She had been well until 2 days before presentation, when she noticed a small pimple-like lesion above the right upper lip that was followed rapidly by facial edema, erythema, and constitutional symptoms.

Her history revealed that she was from a rural area of Albania and had had recent contact with sheep. At presentation, the patient had moderate-grade fever (temperature, 38°C [100.4°F]) and right submandibular lymphadenopathy. The physical examination revealed extensive facial edema and erythema (more pronounced on the right side), which had spread superiorly to the vicinity of the periorbital area, with conjunctival inflammation, and inferiorly toward the neck, causing moderate respiratory distress. Focused examination of the right upper lip revealed 2 painless lesions, 2 × 2 cm and 1 × 1 cm, situated on and above the lip, respectively (A). The lesions were round with raised edges and crusted necrotic centers; they were surrounded by multiple satellite blisters of varying sizes, filled with clear fluid. Gram staining identified the presence of Bacillus anthracis.

Thirty minutes after the initiation of intravenous antibiotic therapy with ciprofloxacin and penicillate crystallite, the patient's face remained asymmetrical and deformed (B) and her respiratory distress was still moderate to severe, mandating elective fiberoptic nasotracheal intubation.

Medical management consisted of nasotracheal intubation for 48 hours to protect airways and 10 days of aggressive intravenous antibiotic therapy. Intravenous prednisone was added because the severe swelling of the patient's upper airway was causing respiratory insufficiency.

As a result of successful intensive critical care, major clinical improvements were observed 5 days after the child's initial presentation (C). The patient was discharged in stable condition on hospital day 10. At a follow-up visit 1 week later, facial and lip soft tissue edema had completely resolved and wound sites had nearly healed.

Anthrax is rare in the Western Hemisphere; however, it remains a public health problem in developing countries, especially those in which farming is the main source of income.¹ Cutaneous anthrax is the most common form of anthrax; it accounts for 95% of cases. The disease develops after contact with infected animals or animal products. The clinical presentation typically includes a painless ulcer(s) with satellite vesicles, malignant edema, and a history of exposure to animals or animal products.^1,2 A chief challenge in diagnosis is distinguishing between cutaneous anthrax and spider bite. Although cutaneous anthrax is relatively simple to treat³ and is self-limited in 80% of patients, complications may arise when the infection goes untreated⁴ or medical attention is sought late. Complications can include progression to septicemia, with potentially lethal CNS involvement,⁵ or respiratory system involvement, as in this girl.

Because cutaneous anthrax is common in children from rural regions in developing countries, clinicians who treat new immigrants from these areas should be aware of the condition and maintain a high index of suspicion when the history (including nationality, traditions, and recent exposure to animals or animal products), physical examination findings, and microbiological laboratory analysis are suggestive. Antibiotic therapy remains the mainstay of medical treatment, followed by steroidal anti-inflammatory therapy for neck and face involvement with respiratory compromise. Elective nasal or oral intubation is a safe and simple method of preventing and treating respiratory compromise in patients with neck and face involvement.

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