Clinical Features

The way anthrax presents itself can differ significantly depending on the specific type of infection:

• Cutaneous Anthrax: Starts as a seemingly harmless, itchy bump resembling an insect bite, which is painless. Within a couple of days, this evolves into a blister (vesicle) and subsequently a painless ulcer, typically 1-3 cm in diameter. A defining feature is the black, dead tissue (eschar) in the centre, resembling a scab. Swollen lymph nodes (lymphadenopathy), swelling (edema), and fever might also be present.

• Inhalation Anthrax: Initially, symptoms are similar to the flu, including fever, cough, tiredness, and muscle pain. As it progresses, more serious signs emerge, such as shortness of breath, chest discomfort, difficulty breathing, shock, and a condition affecting blood clotting known as disseminated intravascular coagulation (DIC).

• Gastrointestinal Anthrax: Characterized by intense abdominal pain, feeling sick to the stomach, throwing up, bloody diarrhoea, and potentially life-threatening blood infection (sepsis).

Definitive Diagnosis and Investigations

Confirmation of diagnosis is based on combining clinical signs, information about potential exposure, and laboratory testing:

• Clinical Examination: A thorough evaluation of the patient’s symptoms and medical background is essential.

• Microscopic Examination: Using Gram staining on samples like blood or wound fluid can reveal the presence of Gram-positive rod-shaped bacteria, which are characteristic of anthrax.

• Culture: Growing and identifying B. anthracis bacteria from samples provides a definitive diagnosis. This requires a high level of safety precautions in the lab.

• Serological Tests: Detecting antibodies against anthrax toxins in the blood can be supportive but isn’t always conclusive on its own.

• PCR (Polymerase Chain Reaction): This technique can detect the genetic material (DNA) of B. anthracis in patient samples.

Management

Goals of Treatment:

• To get rid of the anthrax infection.

• To counteract the harmful substances (toxins) produced by the bacteria.

• To provide supportive care to handle any complications that arise.

Medical Treatment:

The primary approach to treating anthrax is through antibiotic medications:

• First-line Antibiotics: Ciprofloxacin (or other fluoroquinolone antibiotics) or doxycycline are typically used first.

• Alternative Antibiotics: For patients with allergies to fluoroquinolones, other options include penicillin, clindamycin, or vancomycin.

• Treatment Duration: Antibiotics are usually given for a total of 60 days.

Specific Anthrax Types:

• Cutaneous: The vast majority (95%) of anthrax infections occur through skin contact, often via cuts or scrapes. It starts as an itchy raised spot like a bug bite. In a day or two, it becomes a blister and then a painless ulcer, usually 1-3 cm, with a central black necrotic area (eschar). Nearby lymph nodes may swell. Without treatment, cutaneous anthrax leads to death in about 20% of cases. First-line antibiotic is ciprofloxacin 500 mg every 12 hours. Alternatives are doxycycline 100 mg every 12 hours or amoxicillin 1 g every 8 hours.

• Inhalation: Initial symptoms might resemble a common cold. After a few days, breathing difficulties and shock can develop. Inhalation anthrax is often fatal. Besides antibiotics, supportive care such as oxygen, mechanical ventilation, fluids, and shock management may be needed. Raxibacumab (a monoclonal antibody targeting protective antigen) might be used in severe cases.

• Gastrointestinal: Characterized by severe inflammation of the digestive tract. Initial signs include nausea, loss of appetite, vomiting, and fever, followed by abdominal pain, vomiting blood, and severe diarrhoea. Intestinal anthrax is fatal in 25% to 60% of cases.

Nursing Care

Nursing care is centred around:

• Vital Signs Monitoring: Closely tracking breathing, blood pressure, heart rate, and body temperature.

• Respiratory Support: Providing oxygen and assisting with breathing machines (mechanical ventilation) if needed.

• Fluid and Electrolyte Balance: Maintaining proper hydration and monitoring salt and mineral levels in the body.

• Wound Care: For skin anthrax, providing appropriate care to the wound area to aid healing.

• Infection Control: Strictly following infection control measures to prevent spread.

• Psychological Support: Offering emotional support to the patient and their family during this stressful time.

Management Until Discharge

• Continue the prescribed antibiotic course.

• Monitor for any signs of the infection returning or new problems arising.

• Educate the patient about their medication, wound care (if needed), and schedule for follow-up appointments.

Discharge Advice

• Finish the entire course of prescribed antibiotics.

• Watch for any symptoms coming back.

• Report any new or concerning symptoms to their healthcare provider.

• Attend all scheduled follow-up appointments.

Prevention

Animal-Focused Prevention:

• Safe Disposal of Carcasses: Properly burying dead animal bodies, hides, and skins is crucial. Burning is not effective as it can release spores into the air, increasing spread risk.

• Avoid Handling: Do not skin or handle dead animals if anthrax is suspected, as this allows spore formation, which can persist in soil for many years. Meat from these animals should never be eaten.

• Movement Control: Restrict the movement of animals and animal products (like hides or wool) from infected areas to non-infected areas to stop the disease from spreading.

• Mass Animal Vaccination: Implement widespread vaccination programs for livestock in regions known for anthrax outbreaks.

Human-Focused Prevention:

• Vaccination: Anthrax vaccine for humans is recommended for those at high risk of exposure, including:

  1. Lab workers directly handling Bacillus anthracis.

  2. People who work with potentially contaminated animal products (e.g., hides, wool).

  3. Individuals living in or travelling to areas where anthrax is common.

• Health Education: Public awareness campaigns to educate communities about how anthrax spreads, prevention methods, and early symptom recognition. This includes safe handling of animal products and seeking prompt medical attention if exposure is suspected.

Complications

• Sepsis: A dangerous, life-threatening condition where the body has an extreme reaction to an infection.

• Respiratory Failure: A common serious complication of inhalation anthrax.

• Meningitis: Inflammation of the protective membranes surrounding the brain and spinal cord.

• Shock: A critical drop in blood pressure that can be life-threatening.

• DIC (Disseminated Intravascular Coagulation): A condition affecting blood clotting.

• Death: Untreated inhalation and gastrointestinal anthrax have a high risk of death.