Page 24 - Journal of Special Operations Medicine - Summer 2016

remains a common presentation. In a large series of pre-
septal and orbital cellulitis cases in India from 1998 to
2006, it was determined that 5% of children and 21%
Figure 3 Eyelid of adults were infected with anthrax. Perhaps the most
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retraction and corneal important finding in this study is that 39% of the orbital
exposure. cellulitis cases were caused by methicillin-resistant Staph-
ylococcus aureus (MRSA) infection and not anthrax.
MRSA, of course, can be devastating in American tertiary
care centers, so the risk in austere venues is obvious. A
smaller series of three female patients with cicatricial ec-
grafting. She attained acceptable functional results with tropion following preseptal cellulitis showed that two of
improvement in retraction, exposure keratopathy, and the three cases were anthrax positive. Anthrax has been
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cosmesis. Orbicularis oculi and levator palpebris func- associated with corneal scarring and vision loss second-
tion were significantly diminished, however, due to the ary to eyelid malposition. Such scarring is commonly
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excised muscle (Figure 4). Because of the lack of blood seen with trachoma, which remains a leading cause of
supply, the skin graft underwent partial necrosis and blindness worldwide as a consequence of cicatricial lid
healed via secondary intention. malposition and attendant corneal exposure and scar-
ring. However, anthrax should be kept as an option for
differential diagnosis despite its rarity, given the potential
for cutaneous and periorbital infection in endemic areas.
Intentional spread of anthrax is more likely to result in
Figure 4 Final inhalation than cutaneous infection, but a sudden cluster
appearance after full- of unusual or rare cases should signal alarm.
thickness skin graft.
Dental Considerations
SOF medicine often provides dental care to large num-
bers of patients, generating an opportunity for sentinel
event identification. Oral clinical signs and symptoms
such as buccal ulcers and sore throats are not patho-
Discussion gnomic, yet they are still strongly associated with bio-
weapons. These findings of bioterror attacks may likely
Ophthalmic Considerations be first seen in primary care medical and dental clinics,
Published descriptions of periocular anthrax are rare, and previous authors have advocated for a defined role
but this may be because they likely are underreported. for the dentist in detecting outbreaks. Unusual or ab-
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Cutaneous anthrax is the most common form of an- normally greater numbers of presentations of common
thrax, yet, thankfully, reports of periocular manifesta- symptoms are “clues” to a bioterror attack but often
2
tion are uncommon in the literature. 4,5 are difficult to identify in real time. A role for dentistry
in biosurveillance has been hypothetically tested for
Cutaneous anthrax has a characteristic progression, ini- anthrax and tularemia via mathematical assessment of
tially starting as a small pruritic papule at the site of in- buccal ulcers and sore throat findings. Such electronic
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oculation followed by significant painless edema. Black meta-analysis of collected health information may pro-
eschar formation ensues with fibrosis of musculature, vide a rapid strategy for signaling biological attack.
diminished vascular supply, and epidermal scarring.
The extent of the eschar, in our experience, is limited by Relevance to Special Operations Medicine
oculocutaneous retaining ligaments, preventing further Visual/ocular and dental complaints represent a high
skin necrosis. Unfortunately, in the periocular region, percentage of walk-in clinic and outreach visits, so a
these conditions lead to exposure keratopathy, corneal heightened awareness is warranted when working in
ulceration, and scarring. Surgical intervention for cica- endemic anthrax environments. SOF medicine will con-
tricial retraction and ectropion leads to acceptable out- tinue to deploy to austere areas where anthrax is en-
comes for functional protection of the globe. Secondary demic and also potentially encountered as a bioweapon;
staged procedures may be warranted to improve eyelid therefore, providers at all levels are well advised to re-
movement, ptosis, and appearance. view the common presentations and also factors sugges-
tive of intentional exposure.
Periocular anthrax has been reported in India, Africa,
and Turkey. The youngest case reported was in a A detailed review of clinical presentations, vaccines, pro-
6–8
3-year-old child from Zimbabwe. Preseptal cellulitis phylaxis, and treatment guidelines is beyond the scope
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10 Journal of Special Operations Medicine Volume 16, Edition 2/Summer 2016