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

Abstract

BackgroundAnthrax had become extremely rare in Europe, but in 2010 an outbreak of anthrax among heroin users in Scotland increased awareness of contaminated heroin as a source of anthrax. We present the first two Danish cases of injectional anthrax and discuss the clinical presentations, which included both typical and more unusual manifestations.Case presentationsThe first patient, a 55-year old man with HIV and hepatitis C virus co-infection, presented with severe pain in the right thigh and lower abdomen after injecting heroin into the right groin. Computed tomography and ultrasonographic examination of the abdomen and right thigh showed oedematous thickened peritoneum, distended oedematous mesentery and subcutaneous oedema of the right thigh. At admission the patient was afebrile but within 24 hours he progressed to severe septic shock and abdominal compartment syndrome. Cultures of blood and intraperitoneal fluid grew Bacillus anthracis. The patient was treated with meropenem, clindamycin, ciprofloxacin and metronidazole. Despite maximum supportive care including mechanical ventilation, vasopressor treatment and continuous veno-venous hemodiafiltration the patient died on day four.The second patient, a 39-year old man with chronic hepatitis C virus infection, presented with fever and a swollen right arm after injecting heroin into his right arm. The arm was swollen from the axilla to the wrist with tense and discoloured skin. He was initially septic with low blood pressure but responded to crystalloids. During the first week, swelling progressed and the patient developed massive generalised oedema with a weight gain of 40 kg. When blood cultures grew Bacillus anthracis antibiotic treatment was changed to meropenem, moxifloxacin and metronidazole, and on day 7 hydroxycloroquin was added. The patient responded to treatment and was discharged after 29 days.ConclusionsThese two heroin-associated anthrax cases from Denmark corroborate that heroin contaminated with anthrax spores may be a continuous source of injectional anthrax across Europe. Clinicians and clinical microbiologists need to stay vigilant and suspect anthrax in patients with a history of heroin use who present with soft tissue or generalised infection. Marked swelling of affected soft tissue or unusual intra-abdominal oedema should strengthen clinical suspicion.

Injectional anthrax - new presentation of an old disease

“…The second cluster of cases started with the reemergence of a total of 15 cases during June 2012 in six different European countries [9][10][11]14,15,25,26]. The last case was reported in Scotland in March 2013 [10].…”

“…So far, 15 confirmed cases were reported, among them seven fatal, contributing to a 47% case fatality rate (Table 1, Figure 1). Less than half of case reports included epidemiological data such as age and sex, of those who did, the age range varied from 27 to 55 years [10,14,15,25,26].…”

“…To date, no person-to-person transmission was documented in injectional anthrax cases. There seems to be no risk for health workers or for the general population [4,6,8,10,[14][15][16][17][18][19][20][21][22][23][24][25][26].…”

“…Since anthrax is rare in Europe and all cases occurred in drug users, it was assumed that the 2009−2010 outbreak was caused by a contaminated batch of heroin, even though microbiological analysis of heroin samples from a variety of sources in Europe failed to detect contamination with anthrax spores [8,25]. The possibility of deliberate contamination was not eliminated but seemed unlikely due to the affected population [8].…”

Designing inhibitors of anthrax toxin

“…At the same time, numerous research efforts were concentrated on finding ways to disable anthrax toxins by specifically targeting LF or EF. LT traditionally has been considered as the more important factor in anthrax toxicity; however, due to the recently revealed possible role of ET in the anthrax infection of IV-heroin-users in Europe (49), disabling ET could also be critical (36). …”