Subcutaneous anthrax in three intravenous drug users

Abstract

Anthrax is extremely rare in the western world but is endemic to areas of south and central Asia. In early 2010 an outbreak was identified in heroin-injecting intravenous drug users in the United Kingdom and Europe. Afghanistan is currently the principal source of heroin which reaches the United Kingdom. When anthrax occurs, cutaneous disease accounts for over 95% of cases. At least 47 cases with 13 deaths have been confirmed so far. We present three cases presenting during this time with marked swelling, one resulting in compartment syndrome but all with an absence of the expected cutaneous appearances. We suggest that rather than cutaneous anthrax, these patients represent a new subcutaneous presentation of anthrax.

Two anthrax cases with soft tissue infection, severe oedema and sepsis in Danish heroin users

“…They both presented with marked pain and oedema of the affected tissue, which is consistent with earlier descriptions in literature [5,8]. The molecular typing of these two bacterial isolates has recently been described by Grunow et al [7].…”

Lessons for Control of Heroin-Associated Anthrax in Europe from 2009–2010 Outbreak Case Studies, London, UK

“…Patients 1 and 2, as seen in the Scottish anthrax case-patients, exhibited a biphasic illness with an initial recovery, then further deterioration ( 20 , 21 , 22 ). Radiologic features of pulmonary anthrax include pleural effusions, mediastinal widening, paratracheal or hilar fullness, and parenchymal infiltrates.…”

“…Regarding soft tissue infections related to heroin-associated anthrax, the role of surgery was initially unclear, and the suggestion was made that disturbing a lesion may result in clinical deterioration, although this hypothesis remains contentious ( 20 , 21 , 24 ). Based on experiences in Scotland and Health Protection Scotland advice, guidelines from Public Health England (PHE) advocated timely debridement of affected tissue with the aim of reducing the toxin load.…”

Molecular Epidemiologic Investigation of an Anthrax Outbreak among Heroin Users, Europe

“…Injectional anthrax symptoms are more severe than those of cutaneous anthrax and are typified by severe soft tissue infection at the injection site, which can progress to septic shock, meningitis, and death ( 7 ). The origin of anthrax in the Norwegian heroin user was never identified, although contaminated heroin was suspected ( 6 ).…”