Page 23 - Journal of Special Operations Medicine - Summer 2016

Case Report of an Anthrax Presentation
Relevant to Special Operations Medicine

Stephen Winkler, MD; Robert W. Enzenauer, MD, MPH;
James W. Karesh, MD; Nshimyimana Pasteur, MD; Derek L. Eisnor, MD;
Rex B. Painter, DDS; Christopher J. Calvano, MD, PhD

ABSTRACT

Special Operations Forces (SOF) medical personnel Clinical Case
function worldwide in environments where endemic A 17-year-old woman presented to the Brenda Strafford
anthrax (caused by Bacillus anthracis infection) may Institute in Les Cayes, Haiti, with painless periocular
present in one of three forms: cutaneous, pulmonary, edema (Figure 1). She stated that the edema developed
or gastrointestinal. This report presents a rare periocu- rapidly following the appearance of a small lesion in the
lar anthrax case from Haiti to emphasize the need for right lateral canthal area a few days prior to examina-
heightened diagnostic suspicion of unusual lesions likely tion. Her history was significant for recent handling of
to be encountered in SOF theaters. animal carcasses. Given her history and physical pre-
sentation, she was diagnosed with cutaneous anthrax
Keywords: periocular anthrax; Bacillus anthracis; ophthal- and treated with intravenous ceftriaxine. Upon resolu-
mology; diagnostics tion of the edema, a black eschar (Figure 2) developed,
followed by cutaneous hypopigmentation, dermal scar-
ring, and muscular fibrosis, leading to retraction and
exposure keratopathy (Figure 3).
Introduction
Anthrax (B. anthracis) is an encapsulated, gram-positive, Once the scarring had stabilized, she was treated surgi-
nonmotile, aerobic, spore-forming rod bacterium. Clini- cally with excision of the fibrosed skin and orbicularis,
1
cal presentation is most commonly cutaneous, followed lysis of adhesions, and retroauricular full-thickness skin
by pulmonary and gastrointestinal manifestations.
2
Although anthrax is endemic throughout much of the
world, it remains a potent bioweapon and has been used
against the United States. Vaccinations are standard pre-
deployment for US Servicemembers. Effective treatments
are available, yet inhalation/pulmonary anthrax remains Figure 1 Periocular
highly lethal, with five deaths in 22 cases in the well- anthrax presenting as
studied 2001 attack in the United States. 3 acute edema.

SOF medical personnel are likely to encounter endemic
infectious diseases in austere and developing areas, and
they are also at the tip of the spear for initially recogniz-
ing and identifying potential bioterror attacks. For ex-
ample, endemic anthrax outbreaks are rarely seen in the
United States yet are relatively common in emerging na-
tions. The added threat of a bioattack event complicates
the response once the agent is indentified. Although the
case presented here is unusual, it is not the result of in- Figure 2 Eschar
after treatment with
tentional spread. It does highlight the need for a high ceftriaxone and
index of clinical suspicion when evaluating patients who resolution of edema.
have uncommon presentations of common or even un-
common disease. Certainly the rarity of ophthalmic an-
thrax merits consideration of intentional spread should
a cluster of cases arise rather than a single incident.

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