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Epidemiologic Notes and Reports Human Cutaneous Anthrax -- North Carolina, 1987

On July 10, 1987, a 42-year-old male maintenance worker at a North Carolina textile mill noticed a small, red, pruritic, papular lesion on his right forearm. Over the next week, the lesion became vesiculated and then developed a depressed black eschar with surrounding edema. On July 18, 24 hours after beginning treatment with an oral cephalosporin and a topical antifungal agent, he was hospitalized with worsening edema, pain, fever, and chills. Cutaneous anthrax was diagnosed. After the patient was treated with intravenous ampicillin and cephalosporins, his condition improved, and he was discharged on a regimen of oral cephalosporin. Cultures of blood and wound tissue were negative. An electrophoretic immunotransblot assay for antibody to anthrax antigens demonstrated a titer of 512 to anthrax protective antigen and lethal factor (1). The patient's lesion healed with residual local scarring, and he returned to work in late August 1987.

The patient had not traveled recently outside of North Carolina, been exposed to domestic or wild animals, worked with objects made of animal materials other than those at the mill, or used bone meal fertilizer. The textile mill has been in operation for 25 years and employs about 210 workers. No known cases of anthrax have occurred among the workers before, and there has never been a vaccination program. The mill produces yarn from domestic wool and wool imported from Australia and New Zealand; cashmere goat hair from China, Afghanistan, and Iran; and camel hair from China and Mongolia.

To assess the degree of Bacillus anthracis contamination in the mill, investigators collected samples of raw and processed materials and environmental debris from the plant. B. anthracis was grown from 8 (14%) of the 59 samples tested. Five samples of West Asian cashmere were positive for B. anthracis, as was one sample of Australian wool and two samples of surface debris from the storage area. It was not possible to determine whether the cashmere came from Iran or Afghanistan. Upon its arrival in the United States, all cashmere used in the mill is first washed in a plant in Texas and then shipped in bales to North Carolina. Although no cases of anthrax were diagnosed in Texas, eight of 12 cashmere samples (and none of four camel hair samples) obtained at the Texas plant were positive for B. anthracis. A vaccination program for exposed workers at both sites has been recommended (2). Reported by: PM Briggs, RN, BG Delta, MD, SR Keener, MD, Mecklenburg County Health Dept; JI Freeman, DVM, JL Hunter, DVM, JN MacCormack, MD, MPH, State Epidemiologist, North Carolina Dept of Human Resources. JW Ezzell, PhD, Bacteriology Div, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. Bacterial Zoonoses Activity and Meningitis and Special Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases; Div of Field Svcs, Epidemiology Program Office; National Institute for Occupational Safety and Health, CDC.

Editorial Note

Editorial Note: This is the first case of human anthrax to occur in the United States since 1984. Only nine cases have occurred in this country in the past decade. The practice of vaccinating workers involved in the industrial processing of imported animal products and the decline in using fibers of animal origin are the primary factors in the current low incidence of human anthrax in this country (3). Despite the rarity of anthrax, it should be considered in the differential diagnosis of suggestive skin lesions, especially for high-risk persons, such as workers who process materials of animal origin from areas of the world where the disease is endemic and veterinarians and agricultural workers who handle infected animals.

Cutaneous anthrax was diagnosed on the basis of the characteristic skin lesion and the positive immunologic assay. The cultures were probably negative because the patient had been treated with a broad-spectrum antibiotic before sampling. The most likely source of his infection was the textile mill, since he had no other history of exposure and the mill was found to be contaminated with B. anthracis. Maintenance workers in textile mills are at high risk because their duties take them throughout the mill on a regular basis and the nature of their work makes them prone to minor skin injuries that can become contaminated by the bacteria.

The West Asian cashmere was probably the contaminant at the mill. Western Asia is an endemic area for anthrax, and five of the eight positive samples from the mill were from this material. In addition, all of the positive samples from the Texas plant were from cashmere, but none of the camel-hair specimens were positive. The positive sample of Australian wool may have been cross-contaminated because it was stored in the same room as the positive cashmere samples.

This case demonstrates that the potential for occupational transmission of B. anthracis still exists and that careful attention must be given to preventive measures. Such measures include vaccinating potentially exposed workers and educating workers about how anthrax is transmitted.

References

  1. Ezzell JW Jr, Abshire TG. Immunological analysis of cell-associated antigens of Bacillus anthracis. Infect Immun 1988;56:349-56.

  2. Brachman PS, Gold H, Plotkin SA, Fekety FR, Werrin M, Ingraham NR. Field evaluation of a human anthrax vaccine. Am J Public Health 1962;52:632-45.

  3. Brachman PS. Anthrax. In: Eickhoff TC, ed. Practice of medicine. Vol III. Hagerstown, Maryland: Harper and Row, 1978.



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