Indian Journal of Dermatology, Venereology and Leprology Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) ISSN: 0378-6323 EISSN: 0973-3922 Vol. 75, Num. 4, 2009, pp. 416-418

Indian Journal of Dermatology, Venereology and Leprology, Vol. 75, No. 4, July-August, 2009, pp. 416-418

Letter to the Editor

A mini outbreak of cutaneous anthrax in Vizianagaram district, Andhra Pradesh, India

Rao TNarayana, Venkatachalam K, Ahmed Kamal, Padmaja IJyothi, Bharthi M, Rao PAppa

Department of Dermatology, Andhra Medical College, Visakhapatnam, Andhra Pradesh

Correspondence Address:Dr. T. Narayana Rao, Professor and HOD of Dermatology, Res: 15-14-15, Doctor's Enclave, Near Collectors Office, Opp. Sagar Lodge, Visakhapatnam, Andhra Pradesh - 530 002
tnr_derma@yahoo.com

Code Number: 09135

PMID: 19584478

DOI: 10.4103/0378-6323.53158

Sir,
Anthrax is a disease of herbivorous animals caused by Bacillus anthracis and humans incidentally acquire the disease by handling the infected dead animals and their products. ^{[1],[2],[3],[4]} Sporadic cases of cutaneous anthrax by biting flies have been reported. ^[5],[6] Unfortunately, Bacillus anthracis , has also been a potential source for bio- terrorism acts. ^[7] Cutaneous anthrax is the commonest and other two, pulmonary and gastrointestinal anthrax are uncommon forms.
Many regions in India are still enzootic for animal anthrax; however, it is less frequent to absent in North India, and sporadic cases of human anthrax have been reported especially from Southern states of India. ^[8] In Andhra Pradesh, Chittoor, Cuddapah, Guntur, Prakasam and Nellore districts are known endemic areas for animal and human anthrax. ^[9],[10] Recently six tribal patients were described with cutaneous anthrax from a remote tribal area in Visakhapatnam. ^[11] Now four more patients presented with similar clinical features from a different tribal area, which comes under Vizianagaram district, Andhra Pradesh, India.
Four tribal men were brought to the Department of Dermatology during the month of September 2007, with an undiagnosed skin disease of 8-10 days duration. These patients had painless ulcers with vesiculation and edema of the surrounding skin on the extremities without any constitutional symptoms. These cutaneous lesions made us to suspect cutaneous anthrax. There was a history of animal death in their house 10 days prior to the onset of these skin lesions. They did not seek any medical advice for nearly 8 days. Axillary lymphadenopathy was present in one of the four patients and one patient had cervical lymphadenopathy. There were no constitutional symptoms. Patient′s vital data was normal. The clinical details of all cases are given in [Table - 1]. After obtaining the detailed history of contact with an infected carcass and the characteristic clinical features, a diagnosis of cutaneous anthrax was made.
In order to establish our clinical diagnosis, the following investigations were performed. Smears and swabs were taken from vesicles, beneath the ulcers and fluid from the surrounding edematous region. These specimens were sent to the Department of Microbiology, for conventional methods like Gram staining and culture. In addition to these specific investigations, routine blood and biochemical investigations and chest X-ray were done in all cases.
The direct smears of all the four suspected cases revealed thick Gram-positive bacilli. The bacilli were found singly and some showed capsule. These smear findings were suggestive of Bacillus anthracis.
The collected swab exudates were inoculated onto blood agar, which showed non-hemolytic, large, irregular, raised, dull, opaque, grayish white colored colonies with a frosted glass appearance, suggestive of Bacillus anthracis .
All the cases were treated with ciprofloxacin 500 mg twice a day orally and ampicillin 500 mg, eighth hourly orally for a period of two weeks.
Lab diagnosis of cutaneous anthrax depends upon microscopic examination of Gram-stained smears from the lesions and cultures from the skin lesions. Confirmation of cutaneous anthrax depends upon polymerase chain reaction (PCR). ^[1],[7] even in cases of prior antimicrobial therapy. In all our four cases, direct smears from skin lesions showed thick, Gram-positive bacilli and culture-yielded Bacillus anthracis growth, confirming the diagnosis. As the culture showed the growth in all cases, so the test for PCR was not done. All four cases responded dramatically to ciprofloxacin and ampicillin therapy and lesions healed without scar formation.
Anthrax is a disease of public health importance and is a notifiable disease. Once the diagnosis was established in our area, the concerned district health authorities and animal husbandry personnel were informed about existence of anthrax in these areas to take up immediate control measures. [Figure - 1], [Figure - 2]

References

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2.	Hanna P. Anthrax pathogenesis and host response. Curr Trop Microbiol Immunol 1998;225:3-35.  Back to cited text no. 2
3.	Thappa DM, Karthikeyan K. Cutaneous Anthrax: An Indian Perspective. Indian J Dermatol Venereol Leprol 2002;68:316-9.  Back to cited text no. 3  [PUBMED]
4.	Morton MS, Arnold NW. Miscellaneous bacterial infections with cutaneous manifestations. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatrick's, Dermatology in General Medicine. 6 th edition. New York: McGraw - Hill; 2003. p. 1918-21.  Back to cited text no. 4
5.	Turell MJ, Knudson GB. Mechanical transmission of Bacillus anthracis by stable flies ( Stomoxys calcitrans ) and mosquitoes ( Aedes aegypti and Aedes taeniorhynchus ). Infect Immun 1987;55:1859-61.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.	Bradaric N, Punda-Polic V. Cutaneous anthrax due to Penicillin resistant Bacillus anthracis transmitted by an insect bite. Lancet 1992;340:306-7.  Back to cited text no. 6
7.	Wenner KA, Kenner JR. Anthrax. Dermatol Clin 2004:22;247-56.  Back to cited text no. 7
8.	Dutta KK. Emergence of anthrax as an agent of Bio-terrorism. Round Table Conference Series Number 9. New Delhi, India: Ranbaxy Science Foundation; 2001. p. 11-20.  Back to cited text no. 8
9.	Sekhar PC, Singh RS, Sridhar MS, Bhaskar CJ, Rao YS. Outbreak of human anthrax in Ramabhadrapuram Village of Chittor District of Andhra Pradesh. Indian J Med Res 1990;91:448-52.  Back to cited text no. 9  [PUBMED]
10.	Sridhar MS, Chandrasekhar P, Singh J, Jayabhaskar C. Cutaneous anthrax with secondary infection. Indian J Dermatol Venereol Leprol 1991;57:38-40.  Back to cited text no. 10
11.	Raghu Rama Rao G, Padmaja J, Lalitha MK, Rao PVK, Kumar HK, Gopal KVT, et al . Cutaneous anthrax in a remote tribal area - Araku Valley, Visakhapatnam district, Andhra Pradesh, southern India. Int J Dermatol 2007;46:55-8.  Back to cited text no. 11

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