Thursday, August 14, 2014

Eurosurveillance: Anthrax Encounters Of The 4th Kind


Credit CDC 


# 8954


Traditionally there are three ways to contract anthrax. 

  • Cutaneous, or through openings in the skin (the most common form of infection)
  • Gastrointestinal from the consumption of infected meat
  • And inhalational anthrax, from inhaling the spores.


Two years ago in UK: The High Cost Of Getting High we looked at the emergence of a rare 4th way in which people were getting infected with Anthrax in the UK, and across Europe; through the injection of recreational heroin.


In recent years, batches of heroin have been reported across Europe contaminated with anthrax spores, likely an unintentional contamination during the processing or transporting of the drug – and as you might expect – injecting contaminated heroin often turns out badly for the user.


The first cluster was reported in Scotland in 2009, and involved more than 100 cases. Cases resurfaced again in England and parts of Europe in 2012 (see HPA  Case of anthrax confirmed in Oxford). Today the Journal Eurosurveillance  has published a review of the literature, urging that clinicians learn to recognize the signs so that treatment can begin as early as possible.


Eurosurveillance, Volume 19, Issue 32, 14 August 2014

Review articles

Injectional anthrax - new presentation of an old disease

T Berger ()1,2, M Kassirer1, A A Aran1,3

  1. Israel Defense Force, Medical Corps, Ramat-Gan, Israel
  2. Department of Internal Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
  3. Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel

Bacillus anthracis infection (anthrax) has three distinct clinical presentations depending on the route of exposure: cutaneous, gastrointestinal and inhalational anthrax. Each of these can lead to secondary bacteraemia and anthrax meningitis.

Since 2009, anthrax has emerged among heroin users in Europe, presenting a novel clinical manifestation, ’injectional anthrax’, which has been attributed to contaminated heroin distributed throughout Europe; before 2009 only one case was reported. During 2012 and 2013, new cases of injectional anthrax were diagnosed in Denmark, France, Germany, and the United Kingdom. Here we present a comprehensive review of the literature and information derived from different reporting systems until 31 December 2013.

Overall 70 confirmed cases were reported, with 26 fatalities (37% case fatality rate).The latest two confirmed cases occurred in March 2013. Thirteen case reports have been published, describing 18 confirmed cases. Sixteen of these presented as a severe soft tissue infection that differed clinically from cutaneous anthrax, lacked the characteristic epidemiological history of animal contact and ten cases required complimentary surgical debridement. These unfamiliar characteristics have led to delays of three to 12 days in diagnosis, inadequate treatment and a high fatality rate. Clinicians’ awareness of this recently described clinical entity is key for early and successful management of patients.

(Continue . . . )


Of note, no human-to-human transmission has been documented among injectional anthrax cases.  While inhalational anthrax doesn’t spread from human to human, there is a slight risk of transmission from drainage from opens sores that come with the cutaneous form.

Although most of the cases in today’s report presented with serious soft tissue infections – up to, and including necrotising fasciitis - none showed the classic black lesion (eschar) that gives the disease its name (anthrax is Greek for `coal’).



Gastrointestinal, respiratory and neurological symptoms were also described, with disease progression often leading to septic shock, organ failure, and sometimes death.


The authors wrote:


Injectional anthrax presents a challenge for physicians often due to lack of evident case clusters, unfamiliar clinical presentation and severe course of disease. Unlike cutaneous anthrax, injectional anthrax is typically a systemic infection with high mortality rate (Table 4). This may be attributed to the deeper and greater inoculation of spores, higher rates of septicaemia, delayed diagnosis and to factors specific to drug addicts including delayed medical consultation, malnutrition, presence of concomitant diseases such as HIV infection and defective immune response.


For people who inject drugs (PWIDs), anthrax is admittedly pretty far down the list of the bad things that can happen to you.  Even during the biggest outbreak in Scotland,  the incidence was estimated to be only 1.96 infections per thousand addicts.


During the `bad old days’ of the 1970s, I would see 1 or 2 heroin overdoses per shift, and many of them were well beyond any help from the bolus of Narcan (naloxone) I carried when when I arrived.


Beyond simple O.D.s, viral and bacterial infections are a constant danger, and can result in illness and even death. Hepatitis C, Hepatitis B, HIV, wound botulism, Staphylococcus aureus, and even tetanus are among the nasties that drug users are at increased risk of contracting.


While the sharing of needles is the cause of many of these infections, you don’t have to indulge in that particularly unwise practice to end up with a potentially fatal infection. Reusing your own needles, or injecting into a contaminated (dirty) arm, can easily introduce bacteria into the user’s system


Proof, I suppose, that we humans seem to have an infinite capacity to find new ways to wreak havoc on ourselves.


To close this out, a little good news. According to the CDC, this 4th type of Anthrax exposure hasn’t been reported here in the United States.


Injection Anthrax

Recently, another type of anthrax infection has been identified in heroin-injecting drug users in northern Europe. This type of infection has never been reported in the United States.

Symptoms may be similar to those of cutaneous anthrax, but there may be infection deep under the skin or in the muscle where the drug was injected. Injection anthrax can spread throughout the body faster and be harder to recognize and treat. Lots of other more common bacteria can cause skin and injection site infections, so a skin or injection site infection in a drug user does not necessarily mean the person has anthrax.

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