PEDIATRICS Vol. 110 No. 6 December 2002, pp. 1257-1258
More Bioterrorism
To the Editor.—The extensive and informative article about bioterrorism published in the April 2002 issue of Pediatrics1 has some gaps in information that I feel are important to mention.
- The authors suggest that a sputum sample should be sent when suspecting inhalational anthrax. However, anthrax does not cause a truly pneumonic process. When the spores of this organism reach the alveolar space, they are phagocyted by macrophages and transported to the lymphatic system, causing a mediastinal adenitis. Given this fact, the yield of a diagnostic Gram stain or a positive culture from a sputum sample is very low.2 None of the cases of bioterrorism-related inhalational anthrax reported after September 11, 2001, have had a positive sputum culture.
- Although the authors describe the clinical manifestations of gastrointestinal anthrax, they fail to mention that nausea and vomiting are a prominent (and misleading) finding of inhalational anthrax.3
- The authors briefly describe that the initial phase of inhalational anthrax consists of an influenza-like syndrome, but they prefer to categorize the disease as an "agent associated with acute respiratory distress," rather than under "influenza-like illness." The Centers for Disease Control and Prevention has warned about the possible confusion in the diagnosis of these 2 diseases. Inhalational anthrax has occurred mainly in postal workers and persons in contact with contaminated letters. An abnormal chest radiograph was a common initial finding in these patients. Influenza, on the other hand, usually occurs in seasonal epidemics and is transmitted from person to person. The chest radiograph is usually normal. Rapid tests for influenza may be of limited use to differentiate between the 2 entities because of its low sensitivity.4
- Although probably beyond the scope of the article, chemical agents of biowarfare are not mentioned. Several groups of these agents exist, but among the most prominent are the "nerve agents" that can produce an acute cholinergic crisis (Sarin, Tabun, Soman, and VX) and the "vesicant" agents that cause tissue necrosis (mustard and lewisite).5
Miguel G. Madariaga, MD
Section of Infectious Diseases
Rush Medical College
Chicago, IL, 60612
REFERENCES
- Patt HA, Feigin RD. Diagnosis and management of suspected cases of bioterrorism: a pediatric perspective.
Pediatrics.2002; 109
:685
–692
[Abstract/Free Full Text] - Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense.
JAMA.1999; 281
:1735
–1745
[Abstract/Free Full Text] - Jernigan JA, Stephens DS, Ashford DA, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis.2001; 7 :933 –944[Web of Science][Medline]
- Considerations for distinguishing influenza-like illness from inhalational anthrax. MMWR Morb Mortal Wkly Rep.2001; 50 :984 –986[Medline]
- Rosenbloom M, Leikin JB, Vogel SN, Chaudry ZA. Biological and chemical agents: a brief synopsis. Am J Ther.2002; 9 :5 –14[Medline]
In Reply.—
We deeply appreciate the comments made by Dr Madariaga but would like to clarify 1 or 2 of the points that he addressed:
Dr Madariaga indicates that the yield of a diagnostic Gram stain or positive culture from the sputum sample is very low and that none of the cases of bioterrorism-related inhalational anthrax reported after September 11, 2001, had a positive sputum culture. In our report, we emphasized that "laboratory diagnosis of inhalational anthrax relies on blood cultures, as productive cough is not common with the disease ...." We did indicate that sputum should be sent if available.
Dr Madariaga indicates that none of the cases of bioterrorism-related inhalational anthrax reported after September 11, 2001, had a positive sputum culture. In fact, 1 case reported after September 11, 2001, had a positive sputum Gram stain indicating the presence of organisms and a culture might have been positive.1
Dr Madariaga also indicates that we have classified the agent as one that produces acute respiratory distress rather than under the category of influenza-like syndrome. Inhalational anthrax does produce acute respiratory distress even though the prodrome is like an influenza-like illness as clearly stated in paragraph 3 of the description under "Anthrax." We state, "The illness is biphasic, and the initial phase consists of an influenza-like syndrome with fever, myalgia, nonproductive cough, malaise or fussiness, and chest or abdominal pain."
We might disagree with the description that Dr Madariaga has for rapid tests for influenza that he states may be of "limited use to differentiate between the 2 entities due to its low sensitivity." There are a number of different tests for the rapid diagnosis of influenza whose specificity and sensitivity we have summarized in Table 1. We have found that the best of these tests with regard to sensitivity is Directigen Flu A/B, which has a sensitivity better than 90% for influenza A and 86% for influenza B, and a specificity of over 91% for influenza A and 98% for influenza B. Thus, we might conclude that these tests are of somewhat more than "limited use."
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As the author of the letter states, chemical agents of biowarfare were not mentioned nor were they intended to be the subject of this article on biological as opposed to chemical exposures.
Hanoch A. Patt, MD
Ralph D. Feigin, MD
Department of Pediatrics
Baylor College of Medicine
Texas Medical Center
Houston, TX, 77030-3498
REFERENCE
- Inglesby TV, O’Toole T, Henderson DA, et al. Anthrax as a biological weapon in 2002. Updated recommendations on management.
JAMA.2002; 287
:2236
–2252
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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