Clinical Syndromes and Differential Diagnosis

Last updated May 25, 2011

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Clinical Features
Differential Diagnosis
Staging of Inhalational Anthrax
Distinguishing Inhalational Anthrax from ILI and CAP
Pediatric Considerations
Anthrax During Pregnancy
Images
Bibliography

Clinical Features

The three primary forms of anthrax correspond to the route of exposure: cutaneous, inhalational, and gastrointestinal (see References: HPA 2007). A fourth form, anthrax meningitis, may occur as a complication of cutaneous, inhalational, or gastrointestinal anthrax, or it may be the presenting form.

Clinical Features of Cutaneous Anthrax
Feature	Characteristics
Incubation period	1-7 days (more commonly 2-5 days; may be as long as 12 days)
Signs and symptoms^a	—Initial lesion is small papule or vesicle, which may be pruritic. —By second day, papule ulcerates with central necrosis and drying. —Painless, localized, nonpitting edema surrounds ulcerated area. —Fine vesicles may encircle ulcer; these enlarge over next 1-2 days and may discharge serosanguineous fluid. —After 1-2 days, painless black eschar forms over ulcerated area. —Eschar sloughs off after 12-14 days. —Lesions resolve without complications or scarring in 80%-90% of patients. —Extensive nonpitting edema, lymphangitis, and painful lymphadenopathy may occur. —Malignant edema is rare complication and is characterized by severe edema, multiple bullae, and shock.^b —Fever and malaise are common.^a —Lesions tend to occur on exposed areas of body (eg, hands, arms, face, neck). —One outbreak in Thailand demonstrated the following cutaneous findings for 13 patients with cutaneous anthrax^c: ~Eschar (85%) ~Blister (92%) ~Ulcer (23%) ~Edema around lesion (77%) ~Lymphadenopathy (100%)
Case-fatality rate	—Currently <1%^a,g (most patients recover with appropriate antimicrobial therapy) —In preantibiotic era, case-fatality rates of about 20% were reported.^d —A literature review of pediatric anthrax cases identified between 1900 and 2005 demonstrated an overall mortality rate for cutaneous disease of 14% (5 of 37 cases).^e Not all cases in this report received antimicrobial therapy.
Laboratory findings	—Gram stain of lesion may reveal gram-positive rods; neutrophils are uncommon. —WBC count often is normal or may be slightly elevated.^a —Histologic examination shows necrosis, edema, and lymphocytic infiltrate.^f
Abbreviation: WBC, white blood cell. ^aGold 1955. ^bAmadi 1974. ^cKunanusont 1990. ^dSmyth 1941. ^eBravata 2007. ^fDixon 1999. ^gDoganay 2009.

Clinical Features of Inhalational Anthrax
Feature	Characteristics
Incubation period	1-43 days (usually 1-6 days)^a
Signs and symptoms	—Illness may be biphasic, with an initial prodrome (which includes symptoms such as fever, malaise, fatigue, anorexia) followed by sudden increase in fever, severe respiratory distress, diaphoresis, and shock, if left untreated. —Symptoms for 10 patients with inhalational anthrax identified during the 2001 US outbreak^b-c: ~Fever, chills (100%) (7 were febrile on initial presentation) ~Sweats, often drenching (70%) ~Fatigue, malaise, lethargy (100%) ~Cough (minimally or nonproductive) (90%) ~Nausea or vomiting (90%) ~Dyspnea (80%) ~Chest discomfort or pleuritic pain (70%) ~Myalgias (60%) ~Headache (50%) ~Confusion (40%) ~Abdominal pain (30%) ~Sore throat (20%) ~Rhinorrhea (10%) —In the 2001 US outbreak, no evidence of a mild form of inhalational anthrax was detected through follow-up serologic testing of exposed persons.^b —A systematic review of 82 inhalational anthrax cases reported between 1900 and 2005 found that the most common symptoms or findings on admission included the following^d: ~Abnormal lung findings (80%) ~Fever or chills (67%) ~Tachycardia (66%) ~Fatigue or malaise (64%) ~Cough (62%) ~Dyspnea (52%) ~All 26 patients who had chest radiography had abnormal findings, including pleural effusion (69%) or widened mediastinum (54%).
Case-fatality rate	—Sverdlovsk outbreak: 86%^a —US outbreak: 45%^c (lower observed CFR in the US outbreak likely was due to early diagnosis and aggressive therapy) —In a systematic review of 82 cases of inhalational anthrax, the overall CFR was 85%; however, patients in the US 2001 outbreak who received early antibiotic therapy (ie, during the prodromal phase [<4.7 days after illness onset]) had a CFR of 40% and those who received antibiotics >4.7 days after illness onset had a CFR of 75%.^d —A literature review of pediatric anthrax cases identified between 1900 and 2005 demonstrated an overall mortality rate for inhalational disease of 60% (3 of 5 cases).^e Not all cases in this report received antimicrobial therapy.
Laboratory findings	Findings for 10 patients with inhalational anthrax identified during 2001 US outbreak^c: —Median WBC count at presentation was 9,800/mm³(range, 7,500/mm³ to 13,300/mm³) —Differential WBC count >70% neutrophils (70%) —Neutrophil band forms present (4 of 5; 80%) —Peak WBC during illness was 26,400/mm³(range, 11,900/mm³ to 49,600/mm³) —Elevated transaminases (SGOT or SGPT) >40 (90%) —Hypoxemia^f (60%) —Metabolic acidosis (20%) —Abnormal chest radiograph (100%): ~Mediastinal widening (70%) ~Infiltrates, consolidation (70%) ~Pleural effusion (80%) —Abnormal CT scan (8 of 8; 100%): ~Mediastinal lymphadenopathy, widening (7 of 8; 88%) ~Pleural effusion (8 of 8; 100%) ~Infiltrates, consolidation (6 of 8; 75%)
Abbreviations: CFR, case-fatality rate; CT, computed tomography; SGOT, serum glutamic oxalacetic transaminase; SGPT, serum glutamic pyruvic transaminase; WBC, white blood cell. ^aMeselson 1994. ^bBaggett 2005. ^cJernigan 2001. ^dHolty 2006: Systematic review: a century of inhalational anthrax cases from 1900 to 2005. ^eBravata 2007. ^fAlveolar-arterial oxygen gradient >30 Hg on room air; O₂ saturation <94%.

Clinical Features of Gastrointestinal Anthrax
Feature	Characteristics
Incubation period	1-7 days (usually 2-5 days)
Signs and symptoms	—One outbreak of GI anthrax in Uganda demonstrated the following findings in 143 patients^a: ~Fever (may be low-grade) (70%) ~Abdominal tenderness (85%) ~Diarrhea (80%; bloody in only 5%) ~Vomiting (may be coffee-ground or blood-tinged) (90%) ~Headache (100%) ~Pharyngeal edema (10%) —Ascites may develop 2-4 days after onset (fluid may be clear or purulent)^b and in rare instances GI anthrax cases may present with progressive ascites without other classic symptoms.^c —Ulcerations can occur anywhere along the GI tract and may cause hemorrhage, obstruction, or perforation.^d —If the patient survives, symptoms last about 2 wk —One outbreak of oropharyngeal anthrax in Thailand demonstrated the following findings for 24 patients^e: ~Neck swelling (100%) ~Fever (96%) ~Sore throat, dysphagia (63%) ~Mouth or pharyngeal ulcerative or necrotic lesions (100%) (pseudomembranes also were noted in some patients) ~Respiratory distress (25%) ~Hoarseness (8%) ~Sensation of a "lump in throat" (8%) ~Diarrhea (4%) ~Bleeding from the mouth (4%)
Case-fatality rate	—Rate for GI anthrax is between 25% and 60%.^f,j In outbreaks where patients received antibiotic therapy, rates have ranged from 0% to 29%.^g —A literature review of pediatric anthrax cases identified between 1900 and 2005 demonstrated an overall mortality rate for gastrointestinal disease of 65% (13 of 20 cases).^h Not all cases in this report received antimicrobial therapy. —In Thai outbreak of oropharyngeal disease, rate was 13%.^e In another report of 6 cases of pharyngeal anthrax, rate was 50%.ⁱ
Laboratory findings	—Gram stain of peritoneal fluid or oropharyngeal ulcers may demonstrate gram-positive rods. —Median WBC count for 13 patients with oropharyngeal anthrax in Thailand outbreak was 15,635/mm³ (range, 5,100/mm³ to 30,570/mm³). Mean percentage of neutrophils was 79.6% (range, 73% to 91%).^e —B anthracis has been cultured from oropharyngeal swabs and stool specimens in patients with GI anthrax.^g
Abbreviations: GI, gastrointestinal; WBC, white blood cell. ^aNdyabahinduka 1984. ^bDixon 1999. ^cHatami 2010. ^dSirisanthana 2002. ^eSirisanthana 1984. ^fCDC 2001: Investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. ^gBeatty 2003. ^hBravata 2007. ⁱDoganay 1986. ^jDoganay 2009.

Clinical Features of Anthrax Meningitis
Feature	Characteristics
Incubation period	Varies according to primary source of infection.
Signs and symptomsa^a-d	—May occur as complication of cutaneous, inhalational, or gastrointestinal anthrax, and symptoms of primary site of infection usually will be present; however, meningitis may be the presenting illness. —Characteristic features of bacterial meningitis usually present (eg, fever, nuchal rigidity, headache, change in mental status, seizures). —Nausea and/or vomiting are common. —Hemorrhagic meningoencephalitis is a characteristic presentation.
Case-fatality rate^e	—Illness fatal in >90% of cases. —A review of human anthrax in Turkey from 1990 to 2007 identified 5 cases of anthrax meningitis; 100% of cases died despite antibiotic and supportive therapy.^f —A literature review of pediatric anthrax cases identified between 1900 and 2005 demonstrated an overall mortality rate for meningoencephalitis of 100% (6 of 6 cases).^g Not all cases in this report received antimicrobial therapy. —Death usually occurs 1 to 6 days after illness onset, and 75% of patients die within 24 hr of presentation.
Laboratory findings	—Gram stain of CSF reveals many gram-positive rods. —CSF is usually bloody. —Report of 2 cases demonstrated elevated WBC counts in both patients at presentation (24,000 with 84% neutrophils and 18,000 with 90% neutrophils).^b —CT or MRI of head may show focal intracerebral hemorrhage, subarachnoid hemorrhage, diffuse cerebral edema, intraventricular hemorrhage, and/or leptomeningeal enhancement.^d
Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; MRI, magnetic resonance imaging; WBC, white blood cell. ^aDixon 1999. ^bRangel 1975. ^cMeyer 2003. ^dSejvar 2005. ^eLanska 2002. ^fDoganay 2009. ^gBravata 2007.

Differential Diagnosis

The differential diagnosis for anthrax depends upon the clinical syndrome (cutaneous, inhalational, gastrointestinal, or meningeal). Other diagnoses to consider are outlined in the tables below.

Differential Diagnosis for Cutaneous Anthrax
(Note:* Two key features that distinguish cutaneous anthrax from other conditions in differential diagnosis are painlessness of the lesion and the relatively large extent of associated edema.)*
Diagnosis^a-c	Distinguishing Features
Ecthyma gangrenosum	—Usually in neutropenic patients with Pseudomonas aeruginosa bacteremia —Edema usually not present
Ulceroglandular tularemia (Francisella tularensis)	—Clinical course usually indolent; disease often self-limited —Systemic toxicity uncommon
Bubonic plague (Yersinia pestis)	—Systemic toxicity common —Extremely tender regional lymphadenopathy present —Ulceration and eschar formation usually absent
Staphylococcal or streptococcal cellulitis	—May be history of trauma or preexisting lesion at site of infection —Eschar formation does not occur —Usually painful
Necrotizing soft tissue infections (particularly Group A Streptococcus and Clostridium species)	—Severe systemic toxicity often present —Early in course, pain usually more severe than clinical findings would indicate
Bite of brown recluse spider (Loxosceles reclusa)^d	—Brown recluse spiders prefer warm temperatures and are not native to northern half of United States —Spiders tend to hide in barns, woodpiles, and similar places —Bite usually causes painful blister that progresses to necrosis (unlike anthrax, which is painless) —Edema generally absent
Rickettsialpox (Rickettsia akari)	—Initial presentation involves painless papule that forms black eschar —Generalized maculopapular rash appears 2-3 days later
Scrub typhus (Orientia tsutsugamushi; formerly Rickettsia tsutsugamushi)	—Zoonotic infection from chigger bites; occurs in endemic areas (Asia and Western Pacific) —Often associated with generalized maculopapular rash
Orf (orf virus, a parapox virus)	—Occurs in farm workers —Characterized by pustule that progresses to weeping nodule —Eschar formation does not occur —Edema usually absent
Necrotic herpes simplex infection	—More likely to occur in immunocompromised host
^aDixon 1999. ^bSwartz 2001. ^cBell 2002. ^dNelson 2002.

Differential Diagnosis for Inhalational Anthrax
(Note: Features that distinguish inhalational anthrax from other conditions in differential diagnosis include presence of widened mediastinum and pleural effusions on chest radiograph or CT scan with minimal evidence of pneumonia.)
Diagnosis^a,b	Distinguishing Features
Pneumonic plague (Yersinia pestis)	—Hemoptysis relatively common with pneumonic plague, but rare with inhalational anthrax
Tularemia (Francisella tularensis)	—Clinical course usually indolent, lasting weeks —Less likely to be fulminant
Community-acquired bacterial pneumonia —Mycoplasmal pneumonia (Mycoplasma pneumoniae) —Pneumonia caused by Chlamydia pneumoniae —Legionnaires' disease (Legionella pneumophila or other Legionella species) —Psittacosis (Chlamydia psittaci) —Other bacterial agents (eg, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella catarrhalis)	—Rarely as fulminant as inhalational anthrax —Legionellosis and many other bacterial agents (S aureus, S pneumoniae, H influenzae, K pneumoniae, M catarrhalis) usually occur in persons with underlying pulmonary or other disease or in elderly —Bird exposure with psittacosis —Gram stain of sputum may be useful —Community outbreaks caused by other etiologic agents not likely to be as explosive as pneumonic plague outbreak —Outbreaks of S pneumoniae usually institutional —Community outbreaks of Legionnaires' disease often involve exposure to cooling towers
Viral pneumonia —Influenza —Hantavirus —RSV —CMV	—Influenza generally seasonal (October-March in United States) or involves history of recent cruise ship travel or travel to tropics —Exposure to mice infected with hantavirus or their urine or feces —RSV usually occurs in children (although may be cause of pneumonia in elderly); tends to be seasonal (winter/spring) —CMV usually occurs in immunocompromised patients
—Q fever (Coxiella burnetii)	—Exposure to infected parturient cats, cattle, sheep, goats —Severe pneumonia not prominent feature
Abbreviations: CMV, cytomegalovirus; CT, computed tomography; RSV, respiratory syncytial virus. ^aDixon 1999. ^bBell 2002.

Differential Diagnosis for Gastrointestinal Anthrax
Diagnosis	Distinguishing Features
Abdominal Subtype^a
Typhoid fever (Salmonella typhi)	—Ascites usually not present —Other clinical features may be similar
Intestinal tularemia (Francisella tularensis)	—Illness often less severe than that seen with gastrointestinal anthrax —Ascites not present —Less likely to resemble acute abdomen —Fever may be less prominent
Bacillary dysentery (Shigella dysenteriae)	—Ascites usually not present —Other clinical features may be similar
Acute bacterial gastroenteritis caused by other agents (eg, Campylobacter jejuni, Shiga toxin–producing Escherichia coli, Yersinia enterocolitica)	—Illness often less severe than that seen with gastrointestinal anthrax —Ascites not present —Less likely to resemble acute abdomen —Fever may be less prominent —Hemolytic uremic syndrome may occur with infection caused by Shiga toxin–producing E coli
Bacterial peritonitis	—Gastrointestinal symptoms (nausea, vomiting, gastrointestinal bleeding, diarrhea) not prominent features —Tends to occur in persons with underlying medical conditions (eg, alcoholism, other liver disease)
Acute abdomen (eg, appendicitis)^b	—Anthrax generally begins with vague systemic symptoms rather than abdominal pain —Ascites is relatively common with gastrointestinal anthrax and less common with appendicitis and similar conditions
Oropharyngeal Subtype
Diphtheria (Corynebacterium diphtheriae)	—Primarily occurs in nonimmune children under 15 yr of age —Pharyngeal membrane is prominent feature; ulcerative or necrotic lesions generally not present —Removal of pharyngeal membrane often causes bleeding of submucosa
Pharyngeal tularemia (Francisella tularensis)	—Neck swelling usually absent —Exudative pharyngitis common; ulcerative lesions may occur
Streptococcal pharyngitis (Streptococcus pyogenes)	—Exudative pharyngitis most prominent feature; necrotic ulcers generally absent —Neck edema usually absent, although cervical lymphadenopathy may be prominent
Infectious mononucleosis	—Most common in young adults —Splenomegaly commonly occurs —Neck edema usually absent, although cervical lymphadenopathy may be prominent
Enteroviral vesicular pharyngitis (coxsackievirus)	—Small vesicles noted on soft palate, uvula, or anterior tonsillar pillars —Generally occurs in children —Neck edema usually absent
Acute herpetic pharyngitis (herpes simplex virus)	—Vesicles, shallow ulcers may be noted, but lesions usually not necrotic —Neck edema usually absent, although cervical lymphadenopathy may be prominent
Anaerobic pharyngitis (Vincent's angina)	—Purulent exudate covers posterior pharynx —Tonsillar abscesses may occur —Neck edema usually absent
Yersinia enterocolitica pharyngitis	—Exudative pharyngitis most prominent feature —Neck edema usually absent —Cervical adenopathy, abdominal pain may occur
^aDixon 1999. ^bKanafani 2003.

Differential Diagnosis for Anthrax Meningitis
Diagnosis	Distinguishing Features
Subarachnoid hemorrhage	—Fever not usually prominent feature —Can be distinguished by CT without contrast^a
Bacterial meningitis from other causes	—Meningitis not usually hemorrhagic as seen with anthrax meningitis —CSF Gram stain may be useful in diagnosis
Aseptic meningitis	—Meningitis not hemorrhagic —CSF does not show characteristic gram-positive bacilli —CSF usually demonstrates lymphocytosis
Encephalitis	—CSF findings may be variable, depending on etiology —CSF Gram stain may be useful in diagnosis
Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography. ^aDixon 1999.

Staging of Inhalational Anthrax

Historically, inhalational anthrax has been divided into a prodromal phase and a fulminant phase. The table below outlines a proposed staging scheme (Lucey 2005) that adds an intermediate stage in which symptoms are clearly worsening but the illness may still be treated successfully.

Proposed Staging of Inhalational Anthrax
Stage	Comments
1: Asymptomatic	—Usually <1 wk after exposure and rarely >1 mo
2: Early—Prodromal	—Nonspecific malaise, myalgias, low-grade fever, mild headache, nausea, general "flu-like" prodromal illness
3: Intermediate—Progressive	—Blood cultures positive in <24 hr —Mediastinal lymphadenopathy —Pleural effusions that are often hemorrhagic and large and require repeated drainage —Findings may include: high fever, dyspnea, confusion or syncope, increasing nausea/vomiting —Patients at this stage can still be cured with antibiotics and intensive support
4: Late—Fulminant	—Respiratory failure requiring intubation, sepsis, meningitis, end-organ hypoperfusion (ie, "shock") —Cure less likely at this stage —Future therapies for this stage may require inhibitors of both anthrax toxin and systemic inflammatory response, in addition to antibiotics and intensive care
Adapted from Lucey 2005.

Distinguishing Inhalational Anthrax from Influenza-Like Illness (ILI) and Community-Acquired Pneumonia (CAP)

Early symptoms of inhalational anthrax, ILI, and CAP are similar and include fever, chills, myalgias, fatigue, malaise, and cough. However, several features can be used to distinguish these illnesses. One study of symptomatic patients with possible exposure to anthrax found that the presence of nonheadache neurologic symptoms (eg, dizziness, confusion), dyspnea, and upper gastrointestinal tract symptoms (eg, nausea, vomiting) were more suggestive of anthrax, whereas rhinorrhea and sore throat were far more common in patients with viral illnesses (Hupert 2003).

Another study reviewed the CDC guidelines for inhalational anthrax during the 2001 outbreak and found that the guidelines would have missed 10 of the 11 cases (Mayer 2003). The authors found that the modifications to the CDC guidelines shown below in italics would have led to recognition of 8 of the 11 cases.

Fever
Sweats
Fatigue
Cough
Chest discomfort, pleuritic pain
Nausea, vomiting
Headache
Dyspnea
Myalgias
Abdominal pain
Confusion
Fever (low grade: mean temperature, 38°C)
Tachycardia (mean heart rate, 121 beats per minute)
Clinical presentation consistent with inhalational anthrax when five or more of the above symptoms are present, in addition to tachycardia and fever

Howell and colleagues have suggested that use of this revised screening protocol may incur lower medical costs than the screening protocol proposed by Hupert and coworkers (outlined in the first paragragh of this section) and may be similar in its sensitivity to detect anthrax cases (although the numbers of anthrax cases in the comparison study were small) (Howell 2004, Hupert 2003, Mayer 2003).

Another study examined the clinical features of the 2001 inhalational anthrax cases and compared them with those of ILI cases seen in an ambulatory clinic and of hospitalized patients with CAP. On the basis of these comparisons, the authors developed scoring systems for distinguishing ILI and CAP from inhalational anthrax (Kuehnert 2003).

The scoring system for comparing inhalational anthrax with ILI included the following features. Patients with a score of 4 or more were more likely to have inhalational anthrax (sensitivity, 100%; specificity, 96.1%) than those with lower scores.

Low serum albumin (2 points)
Tachycardia (2 points)
No nasal symptoms (2 points)
No myalgias or arthralgias (1 point)
Low serum sodium level (1 point)
No headache (1 point)
High hematocrit or hemoglobin level (1 point)

The scoring system for comparing inhalational anthrax with CAP included the following features. Patients with a score of 2 or more were more likely to have inhalational anthrax (sensitivity, 100%; specificity, 48%) than those with lower scores. When the score was increased to 3 or more, the sensitivity dropped to 82% and the specificity increased to 81%.

Elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels (1 point)
Low serum sodium level (1 point)
Normal white blood cell count (1 point)
Nausea and vomiting (1 point)
Tachycardia (1 point)

A third study, which compared 47 historical anthrax cases (including 11 with bioterrorism-related anthrax) with 376 controls with CAP or ILI, found that the most accurate predictor of anthrax was mediastinal widening or pleural effusion on chest radiograph (Kyriacou 2004).

A report from the CDC included the following table, which compared the clinical features of 10 patients with inhalational anthrax to patients with laboratory-confirmed influenza.

Symptoms and Signs of Inhalational Anthrax, Laboratory-Confirmed Influenza, and Influenza-Like Illness (ILI) from Other Causes
	Inhalational Anthrax^a (%)	Laboratory-Confirmed Influenza (%)	ILI from Other Causes (%)
Elevated temperature	70	68-77	40-73
Fever or chills	100	83-90	75-89
Fatigue/malaise	100	75-94	62-94
Cough	90	84-93	72-80
Shortness of breath	80	6	6
Chest discomfort/pain	60	35	23
Headache	50	84-91	74-89
Myalgias	50	67-94	73-94
Sore throat	20	64-84	64-84
Rhinorrhea	10	79	68
Nausea or vomiting	80	12	12
Abdominal pain	30	22	22
^aN=10. Adapted from CDC 2001. Considerations for distinguishing influenza-like illness from inhalational anthrax.

A literature review of 42 patients who had atypical anthrax presentations (ie, patients with confirmed anthrax infection who did not have known cutaneous, gastrointestinal, or inhalational ports of entry) revealed that these patients were significantly less likely to have cough, chest pain, or abnormal lung findings, even though they most likely had inhalational anthrax (Holty 2006: Anthrax: a systematic review of atypical presentations).

A 2004 study used a decision-analytic model to assess the best treatment strategy for patients presenting with ILI in settings with varying probabilities for inhalational anthrax (Fine 2004). The authors concluded that, for inhalational anthrax probabilities between 0.1% and 2%, when the sensitivity of blood culture exceeds 95%, the best strategy is to treat with a short course of empiric ciprofloxacin until blood culture results are available. During influenza season, the best strategy involves rapid testing for influenza followed by empiric treatment for anthrax pending blood culture results for those who test negative for influenza.

Pediatric Considerations

Reports in the literature support the following observations about anthrax in children.

Inhalational anthrax is uncommon in children. For example, none of the cases in the Sverdlovsk inhalational anthrax outbreak occurred in children (Meselson 1994), and reports of inhalational disease among children are rare.
Naturally occurring cutaneous anthrax also is uncommon in children, probably because children have less opportunity for exposure to infected animals.
Other modes of transmission (such as person-to-person through skin-to-skin contact or transmission via fomites) may be more common for young children who acquire cutaneous anthrax (Freedman 2002).
The skin lesions described for children who have cutaneous anthrax are usually similar to those seen in adults. Progression to severe systemic disease can occur (Freedman 2002).
Anthrax meningitis has been reported in children and may be the presenting feature (Rangel 1975, Tabatabaie 1993).
A review of 73 cases (5 inhalational, 22 gastrointestinal, 37 cutaneous, 6 primary meningoencephalitis, and 3 atypical) in children from 1900 to 2005 noted that children with inhalational anthrax lacked nonheadache neurologic symptoms, a key distinguishing finding (Bravata 2007).
Another review of 62 pediatric cases of anthrax (2 inhalational, 20 gastrointestinal, 37 cutaneous, and 3 atypical) between 1966 and 2005 suggests that infected children may manifest different symptoms than do infected adults and that difficulties in diagnosing the disease in children may lead to delays in care (AHRQ 2006). Children with gastrointestinal anthrax have two distinct clinical presentations, similar to adults; however, children with inhalational anthrax may have atypical presentations, including meningoencephalitis. Clinicians and public health officials must recognize the broad spectrum of potential presentations for timely diagnosis and detection.

Anthrax During Pregnancy

A report summarized two cases of anthrax in pregnant women; the features of these cases are outlined in the table below (Kadanali 2003).

Summary of Clinical Features for Two Pregnant Women with Anthrax
Patient Age	Weeks of Gestation at Illness Onset	Clinical Presentation of Anthrax	Outcome of Pregnancy
33	32	Cutaneous anthrax (treated with penicillin G and prednisone)	—Infant delivered preterm at 35 wk —No evidence of congenital infection
29	33	Cutaneous anthrax (treated with procaine penicillin)	—Infant delivered preterm at 34 wk —No evidence of congenital infection

Images

Cutaneous anthrax images (CDC)
Cutaneous anthrax infection (Roche KJ, Chang MW, Lazarus H. N Engl J Med 2001;345[22]:1611)
Histopathology, microbiology, skin lesions, chest x-ray findings (Public Health Image Library—type "anthrax" in the search field)
Inhalational anthrax images (CDC)
Inhalational anthrax images: histopathology (Armed Forces Institute of Pathology)
Inhalational anthrax images: microbiology (Armed Forces Institute of Pathology)


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