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Letter
Cutaneous Anthrax, Belgian
Traveler
Erwin Van den Enden,*
Alphons Van Gompel,* and Marjan Van Esbroeck*
*Institute of Tropical Medicine, Antwerp, Belgium
Suggested
citation for this article
To the Editor: Anthrax is a rare zoonotic disease among travelers.
The clinical spectrum includes cutaneous lesions, respiratory anthrax,
pharyngeal inflammation, gastrointestinal infection, septicemia, and meningitis.
Interest in anthrax increased after the bioterrorist attacks in the United
States in 2001. The following case history describes a cutaneous infection
suspected to be anthrax in a tourist who had indirect contact with dead
mammals in a disease-endemic area.
After indirect contact with dead antelopes and a hippopotamus in Botswana,
an acute necrotic lesion developed on a finger of a 31-year-old, healthy,
female Belgian woman. The lesion became covered with a black crust, followed
by massive swelling of the hand and arm. The clinical aspect and history
strongly suggested cutaneous anthrax. This diagnosis was supported by
seroconversion to protective antigen of Bacillus anthracis and
the presence of antibodies against lethal factor. The bacterium itself
could not be cultured or identified by polymerase chain reaction (PCR).
Other members of the group with which she traveled were contacted, but
no other cases were reported.
The Belgian woman traveled with friends to Namibia, Botswana, and South
Africa from December 12, 2004, until January 22, 2005. She visited Chobe
National Park in Botswana early January 2005. On January 8, a small, painless,
vesicular lesion developed on the dorsal side of her fourth left finger.
This lesion increased in size quickly and developed a black aspect with
a red elevated border. Small vesicles appeared in the immediate vicinity
of the primary lesion. No pus was noted. Her general condition was good.
She treated herself with amoxicillin-clavulanic acid 2 gm/day for 3 days.
The next day, massive edema of the finger, hand, and left arm developed.
When admitted to a hospital in Johannesburg, her left arm and hand were
massively swollen with painful left axillary lymphadenopathy. Her temperature
never exceeded 37.8°C. Wound cultures showed only the presence of
viridans streptococci, bacteria that are not implicated in wound infections.
The patient was treated with intravenous ciprofloxacin, gentamicin, tetracycline,
flucloxacillin, and topical mupirocin. She was discharged after 6 days
with oral flucloxacillin and returned to Belgium on January 22. On February
4, her general condition was excellent; the edema had diminished. A painless
necrotic lesion on the left fourth finger measured 3 cm2 (Figure).
She mentioned minor discomfort of her left underarm and loss of sensation
at the distal radial side of the left underarm. She could not extend the
terminal phalanx of the fourth left finger because the underlying tendon
had been destroyed. The left axillary lymph nodes were still slightly
swollen. No evidence indicated parapox viral infection or necrotic arachnidism.
Upon questioning, she mentioned that in Chobe National Park, some fellow
travelers had manipulated the legs of dead antelopes. One person had climbed
on a dead hippo for a picture and sank into the putrefying carcass. He
soon afterwards cleaned a small abrasion on the patient's finger. Some
hours later, all group members washed their hands in a common small plastic
basin containing water and chloroxylenol.
Full blood count, erythrocyte sedimentation rate, and biochemistry were
normal. Antistreptolysin O levels were within normal limits. Serologic
test results for rickettsiae, orthopoxviruses, and Bartonella henselae
were negative. The patient was not immunocompromised. Because cutaneous
anthrax was suspected, wound crusts, swabs for bacterial cultures, and
Dacron swabs used for PCR were mailed as quickly as possible to the Belgian
national reference laboratory. All cultures remained sterile. PCR was
negative for B. anthracis. Because of the positive clinical outcome
with antimicrobial drugs for 16 days, no additional antimicrobial drugs
or steroids were prescribed. Further recovery was uneventful and only
a small scar remains. While waiting for serologic test results, a ProMed
alert was issued (1). Members of the travel group
were contacted and warned but no other cases were identified. Consecutive
serum samples were analyzed for B. anthracis protective antigen
antibodies (anti-PA) (Centers for Disease Control and Prevention, Atlanta,
GA, USA). The serum collected on February 4 was negative. On February
16, anti-PA immunoglobulin G (IgG) was detected with a titer of 9.5 (weakly
positive). On April 18, no anti-PA IgG could be detected. Paired serum
samples (February 4 and 16) were also mailed to the Institut für Microbiologie
der Bundeswehr in Munich, Germany. In the German laboratory, the anti-PA
enzyme-linked immunosorbent assay result was negative, but specific antibodies
against lethal factor of B. anthracis were detected.
Anthrax is essentially a disease of grazing animals and is relatively
common in persons who have contact with these animals (2–4).
It is occasionally reported in travelers (5).
In this case, many arguments existed for cutaneous anthrax, but the diagnosis
could not be proven. Clinical symptoms (malignant edema) and history of
indirect contact with carcasses of wildlife in a disease-endemic area
suggested anthrax. Bacterial cultures remained negative, presumably because
of previous administration of antimicrobial drugs. The clinical diagnosis
was supported by seroconversion to protective antigen and the presence
of antibodies against lethal factor. In cutaneous anthrax, antibodies
to protective antigen develop in 68%–92% of cases (6,7).
Previous cases of cutaneous anthrax in Belgium date from the 1980s, when
a man became infected while unloading Indian bone meal in Antwerp Harbor.
In 1986, cutaneous anthrax developed in a Turkish woman after being injured
while cooking a sheep (8). In 2002, a suspected
case in a Belgian farmer was reported (9). Many
cases of cutaneous anthrax heal spontaneously, but a 5%–10% chance of
systemic complications exists. This case illustrates 1 of the dangers
of touching dead animals in nature. Travelers should be warned that even
indirect contact can lead to problems.
Acknowledgments
We thank Wolf Splettstösser
(anthrax serology), Arno Buckendahl (anthrax serology), Hermann Meyer
(Orthopoxvirus serology), Pamela Riley (anthrax serology), Mark Van
Ranst (PCR anthrax), Els Keyaerts (PCR anthrax), and Patrick Butaye
(biosafety level 3 laboratory, culture, and PCR anthrax) for their assistance
in preparing this article.
References
- Van den Enden E, Van Gompel A. Suspected cutaneous
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NO::F2400_P1202_CHECK_DISPLAY,F2400_P1202_PUB_MAIL_ID:X,28280)
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Suggested citation
for this article:
Van den Enden E, Van
Gompel A, Van Esbroeck M. Cutaneous anthrax, Belgian traveler [letter].
Emerg Infect Dis [serial on the Internet]. 2006 Mar [date cited].
Available from http://www.cdc.gov/ncidod/EID/vol12no03/05-1407.htm
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