At the end of 2009, there were 14 cases in Scotland (with 7 deaths) of drug users who developed systemic anthrax following exposure to (suspected) contaminated anthrax. Not all cases have been IDUs - illness is documented in those who smoked heroin only and clinical presentation includes abscesses/fasciitis and inhalational anthrax. Investigations on all the anthrax isolates in Scotland indicate that they are of the same strain. Until now no other cases had been identified outside Scotland.
There has now been a single fatal case of anthrax in a 42year male IDU in Northrhine-Westphalia, Germany. This case has no known travel to Scotland.
This may, therefore, indicate that there is more widespread distribution of a contaminated heroin batch and that cases may yet appear in Ireland.
As before, we would urge that cases of severe soft tissue infection or sepsis in an IDU, death or admission in an IDU, or inhalational anthrax are reported to their local Department of Public Health.
The HPSC's website has information on anthrax
here and infectious diseases and
IDUs here
The following pointers are being used by Scottish colleagues in determining if a presenting IDU may in fact be a possible cases of anthrax - this may aid clinical decision making:
* Any drug user who presents with severe soft tissue infection, including necrotising fasciitis or cellulitis/abscess particularly if associated with tissue oedema (often marked)
* Any drug user who presents with signs of severe sepsis even without evidence of soft tissue infection
* Any drug user who presents with meningitis (particularly haemorrhagic meningitis). Also be suspicious if drug users present/ have CT evidence suggestive of subarachnoid haemorrhage/intracranial bleed)
* Any drug user who presents with signs and symptoms of inhalational anthrax (please note that this is a theoretical risk). The signs and symptoms of inhalational anthrax include:
- Flu-like illness, progressing to severe respiratory difficulties and shock
- Chest x-ray signs (pleural effusions, mediastinal widening, paratracheal fullness, hilar fullness, parenchymal infiltrates)
- Progressively enlarging haemorrhagic pleural effusions are a consistent feature
- The disease is often biphasic, with a prodrome of general malaise for 2-3 days, followed by a day or two of apparent remission before the full blown picture develops
- Respiratory symptoms may also be accompanied by signs and symptoms suggesting meningitis or intracranial bleeding in the rapidly advancing stages of the disease process due to haematogenous spread.
