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of this discussion. However, excellent reference resources 8. Soysal HG, Kiratli H, Recep OF. Anthrax as the cause of pre-
are available for download from the US Army Medical septal cellulitis and cicatricial ectropion. Acta Ophthalmol
Scand. 2001;79:208–209.
Research Institute of Infectious Disease at http://www 9. Caca I, Cakmak SS, Unlu K, et al. Cutaneous anthrax on eye-
.usamriid.army.mil/education/instruct.htm. These include lids. Jpn J Ophthalmol. 2004;48:268–271.
up-to-date medication schedules and dosages. 10. Yorston D, Foster A. Cutaneous anthrax leading to corneal
scarring from cicatricial ectropion. Br J Ophthlmol. 1989;73:
809–811.
Conclusion 11. Flores S, Mills SE, Shackelford L. Dentistry and bioterrorism.
Dent Clin North Am. 2003;47:733–744.
The periocular case presented here provides an excellent 12. Torres-Urquidy MH, Wallstrom G, Schleyer TK. Detection
reminder that providers in austere regions may see un- of disease outbreaks by the use of oral manifestations. J Dent
usual presentations of classic diseases such as anthrax. Res. 2009;88:89–94.
Such normal variants must be distinguished from inten-
tional or weaponized infections. Although periocular
anthrax is rarely reported in the literature, it is a vari-
ant of cutaneous anthrax, which represents 95% of all Dr Winkler is currently the American Society of Ophthalmic
known anthrax infections. Plastic and Reconstructive Surgery Oculoplastic Surgery Fel-
low at the Kriger Eye Institute in Baltimore, Maryland. He has
SOF medicine has the difficult charge of recognizing the interest and experience in tropical and austere medicine and
will be completing his training this June.
individual who has a common disease presentation while
remaining vigilant for signs of both rare manifestations BG Enzenauer is a recently retired M-day Guardsman, hav-
of endemic agents and signs of bioterror attacks. Presen- ing served as the assistant adjutant general for space and mis-
tation of one or several people with unusual periocular sile defense, Colorado Army National Guard, since 2010. In
or perioral lesions should trigger consideration of an- the civilian sector, Dr Enzenauer is currently professor of oph-
thrax when operating in endemic or high-threat regions. thalmology and pediatrics and the chief of ophthalmology at
Prompt recognition of both the type of infection and the the Children’s Hospital of Colorado in Aurora. He is board
means of distribution (endemic versus intentional) are certified in ophthalmology, preventive medicine (aerospace
keys to mitigating morbidity and mortality. medicine), and pediatrics. Dr Enzenauer was commissioned
a Distinguished Cadet from the United States Military Acad-
emy in 1975. In 1979, he received his medical degree from
Acknowledgment the University of Missouri-Columbia School of Medicine, and
This report was presented in part at the American So- completed internship and residency in pediatrics from 1979 to
ciety of Ophthalmic Plastic & Reconstructive Surgery 1982 at Tripler Army Medical Center, Hawaii. He has served
as a pediatrician at Scholfield Barracks, including a rotation
46th Annual Fall Scientific Symposium. November to the PI for Balakatan Tangent Flash and to Honduras with
2015, Las Vegas, Nevada. the 47th Field Hospital at Joint Task Force Bravo, Palmerola,
Honduras; the chief flight surgeon for the 101st Aviation Bri-
Disclosures gade, 101st Airborne Division (Air Assault) with a second tour
at JTF-B in Honduras; and completed a second residency in
The authors have nothing to disclose. ophthalmology at Fitzsimons Army Medical Center in Col-
orado, followed by a pediatric ophthalmology fellowship at
References Toronto’s Hospital for Sick Children. Dr Enzenauer left active
duty in 1994 and joined the Army National Guard in 1995. He
1. Ahluwalia J, Chambers M, Rusnak J, et al. (eds). Quick bio- served as a senior flight surgeon and the battalion surgeon for
agents: USAMRIID’s pocket reference guide to biological se- 5/19th SFG(A), Colorado Army National Guard. He deployed
lect agents & toxins. Fort Detrick, MD: US Army Medical on many Joint Combined Exchange Training operations to the
Research Institute of Infectious Diseases; 2012. http://www.us
amriid.army.mil/education/docs/Quick_Bio-Agents_Giude.pdf Pacific Command from 1998 to 2011, to Afghanistan from
2. Doganay M, Metan G, Alp E. A review of anthrax and its out- 2002 to 2003 during Operation Enduring Freedom 2, and to
come. J Infect Public Health. 2010;3:98–105. Iraq from 2003 to 2004 during Operation Iraqi Freedom 2.
3. Cole L. Bioterrorism: still a threat to the United States? CTC
Sentinel. 2012;5:1–28. Dr Karesh is an oculoplastic surgeon and fellowship precep-
4. Baykam N, Ergonul O, Ilu A, et al. Characteristics of cutane- tor at the Kriger Eye Institute, Baltimore, Maryland.
ous anthrax in Turkey. J Infect Dev Ctries. 2009;3:599–603.
5. Tekin RC, Elen MK, Bosnak V, et al. Anthrax on the lower Dr Pasteur is an attending ophthalmologist at the Brenda
eyelid. Turk Hij Den Biyol Derg. 2001;68:93–96. Strafford Institute, Les Cayes, Haiti.
6. Pandian DG, Babu RK, Chiatra A, et al. Nine years’ review on
preseptal and orbital cellulitis and emergence of community-
acquired methicillin-resistant Staphylococcus aureus in a ter- Dr Eisnor is a board-certified emergency medicine physi-
tiary hospital in India. Indian J Ophthalmol. 2011;59:431–435. cian with over 20 years’ experience and is currently the senior
7. Gilliand G, Starks V, Vrcek I, et al. Periorbital cellulitis due to Medical Toxicology Fellow at Emory University and the Cen-
cutaneous anthrax. Int Ophthalmol. 2015;35:843–845. ters for Disease Control and Prevention, Atlanta, Georgia.

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