Intensive Care Medicine

, Volume 38, Issue 7, pp 1092–1104

An overview of anthrax infection including the recently identified form of disease in injection drug users

  • Caitlin W. Hicks
  • Daniel A. Sweeney
  • Xizhong Cui
  • Yan Li
  • Peter Q. Eichacker



Bacillus anthracis infection (anthrax) can be highly lethal. Two recent outbreaks related to contaminated mail in the USA and heroin in the UK and Europe and its potential as a bioterrorist weapon have greatly increased concerns over anthrax in the developed world.


This review summarizes the microbiology, pathogenesis, diagnosis, and management of anthrax.

Results and conclusions

Anthrax, a gram-positive bacterium, has typically been associated with three forms of infection: cutaneous, gastrointestinal, and inhalational. However, the anthrax outbreak among injection drug users has emphasized the importance of what is now considered a fourth disease form (i.e., injectional anthrax) that is characterized by severe soft tissue infection. While cutaneous anthrax is most common, its early stages are distinct and prompt appropriate treatment commonly produces a good outcome. However, early symptoms with the other three disease forms can be nonspecific and mistaken for less lethal conditions. As a result, patients with gastrointestinal, inhalational, or injectional anthrax may have advanced infection at presentation that can be highly lethal. Once anthrax is suspected, the diagnosis can usually be made with gram stain and culture from blood or tissue followed by confirmatory testing (e.g., PCR). While antibiotics are the mainstay of anthrax treatment, use of adjunctive therapies such as anthrax toxin antagonists are a consideration. Prompt surgical therapy appears to be important for successful management of injectional anthrax.


Bacillus anthracis Anthrax Pathogenesis Diagnosis Treatment 


  1. 1.
    Mock M, Fouet A (2001) Anthrax. Annu Rev Microbiol 55:647–671PubMedCrossRefGoogle Scholar
  2. 2.
    Brachman PS (1980) Inhalation anthrax. Ann N Y Acad Sci 353:83–93PubMedCrossRefGoogle Scholar
  3. 3.
    Kiple KF (1993) The Cambridge world history of human disease. Cambridge University Press, CambridgeCrossRefGoogle Scholar
  4. 4.
    Ringertz SH, Høiby EA, Jensenius M, Maehlen J, Caugant DA, Myklebust A, Fossum K (2000) Injectional anthrax in a heroin skin-popper. Lancet 356:1574–1575PubMedCrossRefGoogle Scholar
  5. 5.
    Tutrone WD, Scheinfeld NS, Weinberg JM (2002) Cutaneous anthrax: a concise review. Cutis 69:27–33PubMedGoogle Scholar
  6. 6.
    Inglesby TV, O’Toole T, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, Friedlander AM, Gerberding J, Hauer J, Hughes J, McDade J, Osterholm MT, Parker G, Perl TM, Russell PK, Tonat K, Working Group on Civilian Biodefense (2002) Anthrax as a biological weapon, 2002: updated recommendations for management. JAMA 287:2236–2252CrossRefGoogle Scholar
  7. 7.
    Kyriacou DN, Adamski A, Khardori N (2006) Anthrax: from antiquity and obscurity to a front-runner in bioterrorism. Infect Dis Clin North Am 20:227–251, viiiPubMedCrossRefGoogle Scholar
  8. 8.
    Eurosurveillance Editorial Team (2006) Probable human anthrax death in Scotland. Euro Surveill 11:E060817.060812Google Scholar
  9. 9.
    Anaraki S, Addiman S, Nixon G, Krahe D, Ghosh R, Brooks T, Lloyd G, Spencer R, Walsh A, McCloskey B, Lightfoot N (2008) Investigations and control measures following a case of inhalation anthrax in east London in a drum maker and drummer, October 2008. Euro Surveill 13:19076PubMedGoogle Scholar
  10. 10.
    Centers for Disease Control and Prevention (CDC) (2006) Inhalation anthrax associated with dried animal hides–Pennsylvania and New York city, 2006. MMWR Morb Mortal Wkly Rep 55:280–282Google Scholar
  11. 11.
    Lerner M (2011) ‘Miracle man’ wins fight with anthrax. In: Star tribune. The Star Tribune Media Company, Minnesota, 30 Aug 2011Google Scholar
  12. 12.
    Klempner MS, Talbot EA, Lee SI, Zaki S, Ferraro MJ (2010) Case records of the Massachusetts general hospital. Case 25-2010. A 24-year-old woman with abdominal pain and shock. N Engl J Med 363:766–777PubMedCrossRefGoogle Scholar
  13. 13.
    International Office of Epizootics, World Health Organization, Food and Agriculture Organization of the United Nations (2008) Anthrax in humans and animals, 4th edn. World Health Organization, GenevaGoogle Scholar
  14. 14.
    Christopher GW, Cieslak TJ, Pavlin JA, Eitzen EM Jr (1997) Biological warfare. A historical perspective. JAMA 278:412–417PubMedCrossRefGoogle Scholar
  15. 15.
    Meselson M, Guillemin J, Hugh-Jones M, Langmuir A, Popova I, Shelokov A, Yampolskaya O (1994) The Sverdlovsk anthrax outbreak of 1979. Science 266:1202–1208PubMedCrossRefGoogle Scholar
  16. 16.
    Jernigan DB, Raghunathan PL, Bell BP, Brechner R, Bresnitz EA, Butler JC, Cetron M, Cohen M, Doyle T, Fischer M, Greene C, Griffith KS, Guarner J, Hadler JL, Hayslett JA, Meyer R, Petersen LR, Phillips M, Pinner R, Popovic T, Quinn CP, Reefhuis J, Reissman D, Rosenstein N, Schuchat A, Shieh WJ, Siegal L, Swerdlow DL, Tenover FC, Traeger M, Ward JW, Weisfuse I, Wiersma S, Yeskey K, Zaki S, Ashford DA, Perkins BA, Ostroff S, Hughes J, Fleming D, Koplan JP, Gerberding JL (2002) Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis 8:1019–1028PubMedCrossRefGoogle Scholar
  17. 17.
    Sweeney DA, Hicks CW, Cui X, Li Y, Eichacker PQ (2011) Anthrax infection. Am J Respir Crit Care Med 184:1333–1341PubMedCrossRefGoogle Scholar
  18. 18.
    United States Central Intelligence Agency (2012) The world factbook: field listing: illicit drugs. Accessed 27 Jan 2012
  19. 19.
    Del Giudice P (2004) Cutaneous complications of intravenous drug abuse. Br J Dermatol 150:1–10PubMedCrossRefGoogle Scholar
  20. 20.
    Powell AG, Crozier JE, Hodgson H, Galloway DJ (2011) A case of septicaemic anthrax in an intravenous drug user. BMC Infect Dis 11:21PubMedCrossRefGoogle Scholar
  21. 21.
    Murray PR, American Society for Microbiology (1995) Manual of clinical microbiology, 6th edn. ASM, WashingtonGoogle Scholar
  22. 22.
    Military Vaccine (MILVAX) Agency (2012) Anthrax vaccine immunization program: resource center. Accessed 27 Jan 2012
  23. 23.
    Friedlander AM (2001) Tackling anthrax. Nature 414:160–161PubMedCrossRefGoogle Scholar
  24. 24.
    Mikesell P, Ivins BE, Ristroph JD (1983) Plasmids, pasteur, and anthrax. ASM News 7:320Google Scholar
  25. 25.
    Bradley KA, Mogridge J, Mourez M, Collier RJ, Young JA (2001) Identification of the cellular receptor for anthrax toxin. Nature 414:225–229PubMedCrossRefGoogle Scholar
  26. 26.
    Tippetts MT, Robertson DL (1988) Molecular cloning and expression of the Bacillus anthracis edema factor toxin gene: a calmodulin-dependent adenylate cyclase. J Bacteriol 170:2263–2266PubMedGoogle Scholar
  27. 27.
    Moayeri M, Leppla SH (2009) Cellular and systemic effects of anthrax lethal toxin and edema toxin. Mol Aspects Med 30:439–455PubMedCrossRefGoogle Scholar
  28. 28.
    Cui X, Moayeri M, Li Y, Li X, Haley M, Fitz Y, Correa-Araujo R, Banks SM, Leppla SH, Eichacker PQ (2004) Lethality during continuous anthrax lethal toxin infusion is associated with circulatory shock but not inflammatory cytokine or nitric oxide release in rats. Am J Physiol Regul Integr Comp Physiol 286:R699–R709PubMedCrossRefGoogle Scholar
  29. 29.
    Cui X, Li Y, Li X, Laird MW, Subramanian M, Moayeri M, Leppla SH, Fitz Y, Su J, Sherer K, Eichacker PQ (2007) Bacillus anthracis edema and lethal toxin have different hemodynamic effects but function together to worsen shock and outcome in a rat model. J Infect Dis 195:572–580PubMedCrossRefGoogle Scholar
  30. 30.
    Sweeney DA, Cui X, Solomon SB, Vitberg DA, Migone TS, Scher D, Danner RL, Natanson C, Subramanian GM, Eichacker PQ (2010) Anthrax lethal and edema toxins produce different patterns of cardiovascular and renal dysfunction and synergistically decrease survival in canines. J Infect Dis 202:1885–1896PubMedCrossRefGoogle Scholar
  31. 31.
    Hicks CW, Cui X, Sweeney DA, Li Y, Barochia A, Eichacker PQ (2011) The potential contributions of lethal and edema toxins to the pathogenesis of anthrax associated shock. Toxins (Basel) 3:1185–1202Google Scholar
  32. 32.
    Hicks CW, Li Y, Okugawa S, Solomon SB, Moayeri M, Leppla SH, Mohanty A, Subramanian GM, Mignone TS, Fitz Y, Cui X, Eichacker PQ (2011) Anthrax edema toxin has cAMP-mediated stimulatory effects and high-dose lethal toxin has depressant effects in an isolated perfused rat heart model. Am J Physiol Heart Circ Physiol 300:H1108–H1118PubMedCrossRefGoogle Scholar
  33. 33.
    Shafazand S, Doyle R, Ruoss S, Weinacker A, Raffin TA (1999) Inhalational anthrax: epidemiology, diagnosis, and management. Chest 116:1369–1376PubMedCrossRefGoogle Scholar
  34. 34.
    Anbarasan E (2010) Anthrax outbreak hits Bangladesh. Accessed 27 Jan 2012
  35. 35.
    Doganay M, Metan G, Alp E (2010) A review of cutaneous anthrax and its outcome. J Infect Public Health 3:98–105PubMedCrossRefGoogle Scholar
  36. 36.
    Kutluk MT, Secmeer G, Kanra G, Celiker A, Aksoyek H (1987) Cutaneous anthrax. Cutis 40:117–118PubMedGoogle Scholar
  37. 37.
    Mallon E, McKee PH (1997) Extraordinary case report: cutaneous anthrax. Am J Dermatopathol 19:79–82PubMedCrossRefGoogle Scholar
  38. 38.
    Sirisanthana T, Navachareon N, Tharavichitkul P, Sirisanthana V, Brown AE (1984) Outbreak of oral-oropharyngeal anthrax: an unusual manifestation of human infection with Bacillus anthracis. Am J Trop Med Hyg 33:144–150PubMedGoogle Scholar
  39. 39.
    Abramova FA, Grinberg LM, Yampolskaya OV, Walker DH (1993) Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979. Proc Natl Acad Sci U S A 90:2291–2294PubMedCrossRefGoogle Scholar
  40. 40.
    Alizad A, Ayoub EM, Makki N (1995) Intestinal anthrax in a two-year-old child. Pediatr Infect Dis J 14:394–395PubMedCrossRefGoogle Scholar
  41. 41.
    Dutz W, Kohout E (1971) Anthrax. Pathol Annu 6:209–248PubMedGoogle Scholar
  42. 42.
    Nalin DR, Sultana B, Sahunja R, Islam AK, Rahim MA, Islam M, Costa BS, Mawla N, Greenough WB (1977) Survival of a patient with intestinal anthrax. Am J Med 62:130–132PubMedCrossRefGoogle Scholar
  43. 43.
    Dixon TC, Meselson M, Guillemin J, Hanna PC (1999) Anthrax. N Engl J Med 341:815–826PubMedCrossRefGoogle Scholar
  44. 44.
    Druett HA, Henderson DW, Packman L, Peacock S (1953) Studies on respiratory infection. I. The influence of particle size on respiratory infection with anthrax spores. J Hyg (Lond) 51:359–371CrossRefGoogle Scholar
  45. 45.
    Holty JE, Bravata DM, Liu H, Olshen RA, McDonald KM, Owens DK (2006) Systematic review: a century of inhalational anthrax cases from 1900 to 2005. Ann Intern Med 144:270–280PubMedGoogle Scholar
  46. 46.
    Vessal K, Yeganehdoust J, Dutz W, Kohout E (1975) Radiological changes in inhalation anthrax. A report of radiological and pathological correlation in two cases. Clin Radiol 26:471–474PubMedCrossRefGoogle Scholar
  47. 47.
    Wood BJ, DeFranco B, Ripple M, Topiel M, Chiriboga C, Mani V, Barry K, Fowler D, Masur H, Borio L (2003) Inhalational anthrax: radiologic and pathologic findings in two cases. Am J Roentgenol 181:1071–1078Google Scholar
  48. 48.
    Lalitha MK, Anandi V, Walter N, Devadatta JO, Pulimood BM (1988) Primary anthrax presenting as an injection “abscess”. Indian J Pathol Microbiol 31:254–256PubMedGoogle Scholar
  49. 49.
    Berdjis CC, Gleiser CA (1964) Experimental subcutaneous anthrax in chimpanzees. Exp Mol Pathol 33:63–75PubMedCrossRefGoogle Scholar
  50. 50.
    Ramsay CN, Stirling A, Smith J, Hawkins G, Brooks T, Hood J, Penrice G, Browning LM, Ahmed S (2010) An outbreak of infection with Bacillus anthracis in injecting drug users in Scotland. Euro Surveill 15(2):pii=19465Google Scholar
  51. 51.
    Booth MG, Hood J, Brooks TJ, Hart A; Health Protection Scotland Anthrax Clinical Network (2011) Anthrax infection in drug users. Lancet 375:1345–1346Google Scholar
  52. 52.
    Radun D, Bernard H, Altmann M, Schöneberg I, Bochat V, van Treeck U, Rippe RM, Grunow R, Elschner M, Biederbick W, Krause G (2010) Preliminary case report of fatal anthrax in an injecting drug user in North-Rhine-Westphalia, Germany, December 2009. Euro Surveill 15(2):pii=19464Google Scholar
  53. 53.
    Beaumont G (2010) Anthrax in a Scottish intravenous drug user. J Forensic Leg Med 17:443–445PubMedCrossRefGoogle Scholar
  54. 54.
    Jallali N, Hettiaratchy S, Gordon AC, Jain A (2011) The surgical management of injectional anthrax. J Plast Reconstr Aesthet Surg 64:276–277PubMedCrossRefGoogle Scholar
  55. 55.
    Parcell BJ, Wilmshurst AD, France AJ, Motta L, Brooks T, Olver WJ (2011) Injection anthrax causing compartment syndrome and necrotising fasciitis. J Clin Pathol 64:95–96PubMedCrossRefGoogle Scholar
  56. 56.
    Knox D, Murray G, Millar M, Hamilton D, Connor M, Ferdinand RD, Jones GA (2011) Subcutaneous anthrax in three intravenous drug users: a new clinical diagnosis. J Bone Joint Surg Br 93:414–417PubMedCrossRefGoogle Scholar
  57. 57.
    Johns N, Cooper D, Terrace J (2011) An unusual case of peritonitis in an intravenous drug user. Gastroenterology 141:435–436, 780–781PubMedCrossRefGoogle Scholar
  58. 58.
    Centers for Disease Control and Prevention (CDC) (2001) Update: investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR Morb Mortal Wkly Rep 50:889–893Google Scholar
  59. 59.
    Centers for Disease Control and Prevention (CDC) (2001) Update: investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR Morb Mortal Wkly Rep 50:941–948Google Scholar
  60. 60.
    Centers for Disease Control and Prevention (CDC) (2001) Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. JAMA 286:2226–2232CrossRefGoogle Scholar
  61. 61.
    Stern EJ, Uhde KB, Shadomy SV, Messonnier N (2008) Conference report on public health and clinical guidelines for anthrax. Emerg Infect Dis 14:07–0969PubMedCrossRefGoogle Scholar
  62. 62.
    Athamna A, Massalha M, Athamna M, Nura A, Medlej B, Ofek I, Bast D, Rubinstein E (2004) In vitro susceptibility of Bacillus anthracis to various antibacterial agents and their time-kill activity. J Antimicrob Chemother 53:247–251PubMedCrossRefGoogle Scholar
  63. 63.
    National Services Scotland (2011) Interim clinical management of suspected anthrax in drug users. Available via Accessed 13 Dec 2011
  64. 64.
    Emergent BioSolutions Inc. (2009) Emergent BioSolutions announces commencement of phase I/II clinical trial of anthrax immune globulin for treating anthrax disease. Rockville, 17 March 2009Google Scholar
  65. 65.
    Centers for Disease Control and Prevention (CDC) (2006) E-IND protocol: one time emergency use of liquid 5% anthrax immune globulin for treatment of severe anthrax. CDC, Atlanta, 22 February 2006Google Scholar
  66. 66.
    Cui X, Li Y, Moayeri M, Choi GH, Subramanian GM, Li X, Haley M, Fitz Y, Feng J, Banks SM, Leppla SH, Eichacker PQ (2005) Late treatment with a protective antigen-directed monoclonal antibody improves hemodynamic function and survival in a lethal toxin-infused rat model of anthrax sepsis. J Infect Dis 191:422–434PubMedCrossRefGoogle Scholar
  67. 67.
    Migone TS, Subramanian GM, Zhong J, Healey LM, Corey A, Devalaraja M, Lo L, Ullrich S, Zimmerman J, Chen A, Lewis M, Meister G, Gillum K, Sanford D, Mott J, Bolmer SD (2009) Raxibacumab for the treatment of inhalational anthrax. N Engl J Med 361:135–144PubMedCrossRefGoogle Scholar
  68. 68.
    Human Genome Sciences (HGS) (2011) Raxibacumab (ABthrax). Accessed 15 Dec 2011
  69. 69.
    Chen Z, Moayeri M, Crown D, Emerson S, Gorshkova I, Schuck P, Leppla SH, Purcell RH (2009) Novel chimpanzee/human monoclonal antibodies that neutralize anthrax lethal factor, and evidence for possible synergy with anti-protective antigen antibody. Infect Immun 77:3902–3908PubMedCrossRefGoogle Scholar
  70. 70.
    Chen Z, Moayeri M, Zhao H, Crown D, Leppla SH, Purcell RH (2009) Potent neutralization of anthrax edema toxin by a humanized monoclonal antibody that competes with calmodulin for edema factor binding. Proc Natl Acad Sci U S A 106:13487–13492PubMedCrossRefGoogle Scholar
  71. 71.
    Li G, Qu Y, Cai C, Kong Y, Liu S, Zhang J, Zhao J, Fu L, Xu J, Chen W (2009) The inhibition of the interaction between the anthrax toxin and its cellular receptor by an anti-receptor monoclonal antibody. Biochem Biophys Res Commun 385:591–595PubMedCrossRefGoogle Scholar
  72. 72.
    Hull AK, Criscuolo CJ, Mett V, Groen H, Steeman W, Westra H, Chapman G, Legutki B, Baillie L, Yusibov V (2005) Human-derived, plant-produced monoclonal antibody for the treatment of anthrax. Vaccine 23:2082–2086PubMedCrossRefGoogle Scholar
  73. 73.
    Albrecht MT, Li H, Williamson ED, LeButt CS, Flick-Smith HC, Quinn CP, Westra H, Galloway D, Mateczun A, Goldman S, Groen H, Baillie LW (2007) Human monoclonal antibodies against anthrax lethal factor and protective antigen act independently to protect against Bacillus anthracis infection and enhance endogenous immunity to anthrax. Infect Immun 75:5425–5433PubMedCrossRefGoogle Scholar
  74. 74.
    Wild MA, Kumor K, Nolan MJ, Lockman H, Bowdish KS (2007) A human antibody against anthrax protective antigen protects rabbits from lethal infection with aerosolized spores. Hum Antibodies 16:99–105PubMedGoogle Scholar
  75. 75.
    Vitale L, Blanset D, Lowy I, O’Neill T, Goldstein J, Little SF, Andrews GP, Dorough G, Taylor RK, Keler T (2006) Prophylaxis and therapy of inhalational anthrax by a novel monoclonal antibody to protective antigen that mimics vaccine-induced immunity. Infect Immun 74:5840–5847PubMedCrossRefGoogle Scholar
  76. 76.
    Wang F, Ruther P, Jiang I, Sawada-Hirai R, Sun SM, Nedellec R, Morrow PR, Kang AS (2004) Human monoclonal antibodies that neutralize anthrax toxin by inhibiting heptamer assembly. Hum Antibodies 13:105–110PubMedGoogle Scholar
  77. 77.
    Zhao P, Liang X, Kalbfleisch J, Koo HM, Cao B (2003) Neutralizing monoclonal antibody against anthrax lethal factor inhibits intoxication in a mouse model. Hum Antibodies 12:129–135PubMedGoogle Scholar
  78. 78.
    Lim NK, Kim JH, Oh MS, Lee S, Kim SY, Kim KS, Kang HJ, Hong HJ, Inn KS (2005) An anthrax lethal factor-neutralizing monoclonal antibody protects rats before and after challenge with anthrax toxin. Infect Immun 73:6547–6551PubMedCrossRefGoogle Scholar
  79. 79.
    Bouzianas DG (2010) Current and future medical approaches to combat the anthrax threat. J Med Chem 53:4305–4331PubMedCrossRefGoogle Scholar
  80. 80.
    Sherer K, Li Y, Cui X, Eichacker PQ (2007) Lethal and edema toxins in the pathogenesis of Bacillus anthracis septic shock: implications for therapy. Am J Respir Crit Care Med 175:211–221PubMedCrossRefGoogle Scholar
  81. 81.
    Medical Letter consultants (1998) Anthrax vaccine. Med Lett Drugs Ther 40:52–53Google Scholar
  82. 82.
    Baillie L, Townend T, Walker N, Eriksson U, Williamson D (2004) Characterization of the human immune response to the UK anthrax vaccine. FEMS Immunol Med Microbiol 42:267–270PubMedCrossRefGoogle Scholar
  83. 83.
    Vietri NJ, Purcell BK, Lawler JV, Leffel EK, Rico P, Gamble CS, Twenhafel NA, Ivins BE, Heine HS, Sheeler R, Wright ME, Friedlander AM (2006) Short-course postexposure antibiotic prophylaxis combined with vaccination protects against experimental inhalational anthrax. Proc Natl Acad Sci U S A 103:7813–7816PubMedCrossRefGoogle Scholar
  84. 84.
    Centers for Disease Control and Prevention (CDC) (2002) Use of anthrax vaccine in response to terrorism: supplemental recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 51:1024–1026Google Scholar
  85. 85.
    Centers for Disease Control and Prevention (CDC) (2008) Summary report of the meeting of the advisory committee on immunization practices (ACIP). Atlanta, 22–23 October 2008. Available via Accessed 27 Jan 2012
  86. 86.
    Sherer K, Li Y, Cui X, Li X, Subramanian M, Laird MW, Moayeri M, Leppla SH, Fitz Y, Su J, Eichacker PQ (2007) Fluid support worsens outcome and negates the benefit of protective antigen-directed monoclonal antibody in a lethal toxin-infused rat Bacillus anthracis shock model. Crit Care Med 35:1560–1567PubMedCrossRefGoogle Scholar
  87. 87.
    Li Y, Cui X, Su J, Haley M, Macarthur H, Sherer K, Moayeri M, Leppla SH, Fitz Y, Eichacker PQ (2009) Norepinephrine increases blood pressure but not survival with anthrax lethal toxin in rats. Crit Care Med 37:1348–1354PubMedCrossRefGoogle Scholar
  88. 88.
    Barochia AV, Cui X, Sun J, Li Y, Solomon SB, Migone TS, Subramanian GM, Bolmer SD, Eichacker PQ (2012) Protective antigen antibody augments hemodynamic support in anthrax lethal toxin shock in canines. J Infect Dis 205:818–829PubMedCrossRefGoogle Scholar
  89. 89.
    Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M, Tapper M, Fisk TL, Zaki S, Popovic T, Meyer RF, Quinn CP, Harper SA, Fridkin SK, Sejvar JJ, Shepard CW, McConnell M, Guarner J, Shieh WJ, Malecki JM, Gerberding JL, Hughes JM, Perkins BA, Team ABI (2001) Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerging Infect Dis 7:933–944PubMedCrossRefGoogle Scholar
  90. 90.
    Walsh JJ, Pesik N, Quinn CP, Urdaneta V, Dykewicz CA, Boyer AE, Guarner J, Wilkins P, Norville KJ, Barr JR, Zaki SR, Patel JB, Reagan SP, Pirkle JL, Treadwell TA, Messonnier NR, Rotz LD, Meyer RF, Stephens DS (2007) A case of naturally acquired inhalation anthrax: clinical care and analyses of anti-protective antigen immunoglobulin G and lethal factor. Clin Infect Dis 44:968–971PubMedCrossRefGoogle Scholar
  91. 91.
    Sejvar JJ, Tenover FC, Stephens DS (2005) Management of anthrax meningitis. Lancet Infect Dis 5:287–295PubMedCrossRefGoogle Scholar
  92. 92.
    Doust JY, Sarkarzadeh A, Kavoossi K (1968) Corticosteroid in treatment of malignant edema of chest wall and neck (anthrax). Dis Chest 53:773–774PubMedCrossRefGoogle Scholar
  93. 93.
    Lanska DJ (2002) Anthrax meningoencephalitis. Neurology 59:327–334PubMedCrossRefGoogle Scholar
  94. 94.
    Webster JI, Tonelli LH, Moayeri M, Simons SS Jr, Leppla SH, Sternberg EM (2003) Anthrax lethal factor represses glucocorticoid and progesterone receptor activity. Proc Natl Acad Sci U S A 100:5706–5711PubMedCrossRefGoogle Scholar
  95. 95.
    Pile JC, Malone JD, Eitzen EM, Friedlander AM (1998) Anthrax as a potential biological warfare agent. Arch Intern Med 158:429–434PubMedCrossRefGoogle Scholar
  96. 96.
    Heymann DL, Association American Public Health (2008) Control of communicable diseases manual, 19th edn. American Public Health Association, WashingtonGoogle Scholar
  97. 97.
    Mandell GL, Douglas RG, Bennett JE et al (2005) Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, 6th edn. Elsevier Churchill Livingstone, PhiladelphiaGoogle Scholar

Copyright information

© Springer-Verlag (outside the USA) 2012

Authors and Affiliations

  • Caitlin W. Hicks
    • 1
    • 2
  • Daniel A. Sweeney
    • 3
  • Xizhong Cui
    • 4
  • Yan Li
    • 4
  • Peter Q. Eichacker
    • 4
  1. 1.Cleveland Clinic Lerner College of MedicineClevelandUSA
  2. 2.Howard Hughes Medical Institute, National Institutes of Health Research Scholar, National Institutes of HealthBethesdaUSA
  3. 3.Medical Intensivist ProgramWashington HospitalFremontUSA
  4. 4.Critical Care Medicine Department, Clinical CenterNational Institutes of HealthBethesdaUSA

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