Injectional anthrax in a heroin skin-popper

Ringertz, Signe; Høiby, E. Arne; Jensenius, Mogens; Caugant, Dominique A.; Myklebust, Arne T.; Fossum, Kåre

doi:10.1016/s0140-6736(00)03133-0

Cited by 110 publications

(84 citation statements)

References 2 publications

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“…Positive controls included sections prepared from formalin-fixed, paraffin-embedded B. anthracis grown in culture and tissues obtained from confirmed animal and fatal human anthrax cases. 46 Negative controls consisted of the following: 1) each patient's tissue sections incubated with an IgM antibody reactive with an irrelevant infectious …”

Section: Methodsmentioning

confidence: 99%

The Critical Role of Pathology in the Investigation of Bioterrorism-Related Cutaneous Anthrax

Shieh

Guarner

Paddock

et al. 2003

The American Journal of Pathology

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Cutaneous anthrax is a rare zoonotic disease in the United States. The clinical diagnosis traditionally has been established by conventional microbiological methods, such as culture and gram staining. However, these methods often yield negative results when patients have received antibiotics. During the bioterrorism event of 2001, we applied two novel immunohistochemical assays that can detect Bacillus anthracis antigens in skin biopsy samples even after prolonged antibiotic treatment. These assays provided a highly sensitive and specific method for the diagnosis of cutaneous anthrax, and were critical in the early and rapid diagnosis of 8 of 11 cases of cutaneous anthrax during the outbreak investigation. Skin biopsies were obtained from 10 of these 11 cases, and histopathological findings included various degrees of ulceration, hemorrhage, edema, coagulative necrosis, perivascular inflammation, and vasculitis. Serology was also an important investigation tool, but the results required several weeks because of the need to test paired serum specimens. Other tests, including culture, special stains, and polymerase chain reaction assay, were less valuable in the diagnosis and epidemiological investigation of these cutaneous anthrax cases. This report underscores the critical role of pathology in investigating potential bioterrorism events and in guiding epidemiological studies, Anthrax captured worldwide attention and aroused serious public health concerns following the intentional release of the etiological agent Bacillus anthracis in the United States postal system during Fall 2001, 1,2 resulting in 11 cases of inhalational anthrax and 11 cases of cutaneous anthrax. [3][4][5][6][7] In its conventional form, cutaneous anthrax accounts for 95% of all naturally occurring B. anthracis infections in the United States. 8 -11 Patients often have a history of occupational contact with animals or animal products contaminated with B. anthracis spores. 12-14 These pathogenic spores are introduced through a cutaneous cut or abrasion, with the most common areas of exposure are the head, neck, and extremities, although any area can be involved. Bacteremia and toxemia following cutaneous infection can occur with a fatality rate of 20% to 25% among untreated cases. [15][16][17] Cutaneous anthrax is characterized by the formation of a black eschar surrounded by prominent edema and vesicles, which may resemble many other skin lesions, such as the brown recluse spider bite, 18 -21 ulceroglandular tularemia, 22,23 plague, 24,25 ecthyma gangrenosum, 26,27 various spotted fever group rickettsial infections, 28 -31 and scrub typhus. 32,33 The clinical diagnosis of cutaneous anthrax is traditionally established by microbiological methods (eg, demonstrating gram-positive, capsulated bacilli on the smear of the lesion or isolating B. anthracis in culture). 34,35 However, gram stain and culture for B. anthracis can be unrevealing for patients who receive antibiotic therapy before specimens are obtained. 36,37 Historically, skin biopsies ...

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Section: Methodsmentioning

confidence: 99%

The Critical Role of Pathology in the Investigation of Bioterrorism-Related Cutaneous Anthrax

Shieh

Guarner

Paddock

et al. 2003

The American Journal of Pathology

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“…Endosporeforming bacteria, including Clostridium botulinum [4][5][6], C. tetani [7] and Bacillus anthracis [8], are increasingly recognised as a group of agents infecting injecting drug users (IDUs). These agents are particularly problematic in this patient group because of their occurrence in the intestinal tract, widespread distribution in the environment, the robust nature of bacterial endosopores and their resistance to the process of drug preparation [9].…”

Section: Introductionmentioning

confidence: 99%

An investigation into the microflora of heroin

McLauchlin¹,

Mithani²,

Bolton³

et al. 2002

Journal of Medical Microbiology

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In 2000, an unusual increase of morbidity and mortality among illegal injecting drug users in the UK and Ireland was reported and Clostridium novyi was identified as the likely source of the serious infection, although infections due to C. botulinum and Bacillus cereus were also reported. Because heroin was a possibile source of infection, this study investigated the microflora of heroin samples seized in England during 2000 and 2002. Two methods were developed for the examination of the microflora of heroin. The first consisted of suspension of the drug in maximum recovery diluent (MRD) which was inoculated directly into Clostridium Botulinum Isolation Cooked Meat Broth (CBI). The second method rendered the heroin soluble in citric acid, concentrated particulate material (and bacterial cells) by filtration and removed heroin residues by washing with citric acid and phosphate-buffered saline before placing the filter in CBI broth. Duplicate CBI broths from both methods were incubated without heating and after heating at 608C for 30 min. Subcultures were made after incubation for 7 and 14 days on to eight different solid media. The methods were evaluated with heroin samples spiked with either C. botulinum or C. novyi spore suspensions; recovery of 10 spores in the original sample was demonstrated. Fifty-eight heroin samples were tested by citric acid solubilisation and 34 by the MRD suspension technique. Fifteen different grampositive species of four genera were recognised. No fungi were isolated. Aerobic endospore-forming bacteria (Bacillus spp. and Paenibacillus macerans) were the predominant microflora isolated and at least one species was isolated from each sample. B. cereus was the most common species and was isolated from 95% of all samples, with B. licheniformis isolated from 40%. Between one and five samples yielded cultures of B. coagulans, B. laterosporus, B. pumilus, B. subtilis and P. macerans. Staphylococcus spp. were isolated from 23 (40%) samples; S. warneri and S. epidermidis were the most common and were cultured from 13 (22%) and 6 (10%) samples respectively. One or two samples yielded cultures of S. aureus, S. capitis and S. haemolyticus. The remainder of the flora detected comprised two samples contaminated with C. perfringens and two samples with either C. sordellii or C. tertium. Multiple bacterial species were isolated from 43 (74%) samples, a single species from the remaining 15. In 13 samples B. cereus alone was isolated, in one B. subtilis alone and in one sample B. pumilus alone. C. botulinum and C. novyi were not isolated from any of the heroin samples. Recommendations for the optimal examination of the microflora of heroin are given.

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“…It was Ringertz et al who first described a new route of infection for the pathogen Bacillus anthracis, the causative organism of the disease anthrax, in the year 2000 [2]. In contrast to the classical etiology of the disease (inhalational, cutaneous or gastrointestinal), this newly described injectional anthrax (IA) route, involved 'skin-popping' or injection of heroin contaminated with anthrax spores directly into the subcutaneous tissue.…”

Section: Bacillus Anthracis Classical Disease Etiology and 'Skin-popping'mentioning

confidence: 99%