On October 9, 2001, a letter containing anthrax spores was mailed from New Jersey to Washington, DC. The letter was processed at a major postal facility in Washington, DC, and opened in the Senate's Hart Office Building on October 15. Between October 19 and October 26, there were 5 cases of inhalational anthrax among postal workers who were employed at that major facility or who handled bulk mail originating from that facility. The cases of 2 postal workers who died of inhalational anthrax are reported here. Both patients had nonspecific prodromal illnesses. One patient developed predominantly gastrointestinal symptoms, including nausea, vomiting, and abdominal pain. The other patient had a "flulike" illness associated with myalgias and malaise. Both patients ultimately developed dyspnea, retrosternal chest pressure, and respiratory failure requiring mechanical ventilation. Leukocytosis and hemoconcentration were noted in both cases prior to death. Both patients had evidence of mediastinitis and extensive pulmonary infiltrates late in their course of illness. The durations of illness were 7 days and 5 days from onset of symptoms to death; both patients died within 24 hours of hospitalization. Without a clinician's high index of suspicion, the diagnosis of inhalational anthrax is difficult during nonspecific prodromal illness. Clinicians have an urgent need for prompt communication of vital epidemiologic information that could focus their diagnostic evaluation. Rapid diagnostic assays to distinguish more common infectious processes from agents of bioterrorism also could improve management strategies.

has emphasized the necessity for health care practitioners to be familiar with the manifestations of inhalational anthrax. A wide variety of health care practitioners, including radiologists and pathologists, have the potential to alert other physicians to the possibility of inhalational anthrax because the clinical manifestations of early disease are nonspecific, consisting of flulike symptoms, fever, sweats, malaise, and myalgias. In the absence of known exposure to B. anthracis, the appropriate cultures may not be obtained, and potentially life-saving therapy may not be instituted in a timely manner. The predicted case fatality of inhalational anthrax from historical data was approximately 90% [1]. The United States outbreak showed that with early diagnosis and institution of antimicrobial therapy, mortality can be substantially reduced [2]. In addition, timely identification of inhalational anthrax cases is important so that appropriate public health and law enforcement officials can be notified and can take necessary measures to limit morbidity and mortality. Such notification allows other patients and clinicians to be alerted about the potential for new exposure and allows evidence about the perpetrator to be collected expeditiously. The clinical histories of the 11 cases of bioterrorism-related inhalational anthrax in the United States have been described in detail in several recent publications [2-7]. Here we describe the clinical course of two of the affected patients, with emphasis on imaging findings, in an effort Address correspondence to B. J. Wood