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• Cutaneous.
• Inhalational.
• Gastrointestinal.
If untreated, anthrax in all forms can lead to septicemia and death. Anthrax generally is not
contagious, but person-to-person transmission from cutaneous lesions has been reported rarely.
For more information, see http://www.bt.cdc.gov/agent/anthrax/index.asp.
Signs and symptoms. Symptoms usually occur within 2 weeks of exposure; however, the
incubation period for inhalational anthrax may be as long as several months because of spore
dormancy and delayed clearance from the lungs.
Cutaneous anthrax. Cutaneous anthrax is the most common type of infection (>95%). It usually
develops after skin contact with contaminated meat, wool, hides, or leather from infected
animals. The incubation period ranges from 1 to 12 days. The skin infection begins as a small
papule and progresses to a vesicle in 1 to 2 days, followed by a painless, necrotic ulcer with a
black eschar, usually 1–3 cm in diameter (Figure 4.3). Patients may have fever, malaise,
headache, and regional lymphadenopathy.
Inhalational anthrax. Inhalational disease is the most lethal form of anthrax. The incubation time
of inhalational anthrax in people is unclear, but it is reported to range from 1 to 7 days, possibly
up to 60 days. Initial symptoms resemble common respiratory infections and include mild fever,
muscle aches, and malaise. Some patients also complain of sore throat. These symptoms progress
to nonproductive cough, pleuritic chest pain, shortness of breath, respiratory failure, and
frequently, meningitis. Upper respiratory symptoms such as rhinorrhea are generally not seen
with inhalational anthrax.
Gastrointestinal anthrax. Gastrointestinal disease is the least common form of anthrax. It usually
follows the consumption of raw or undercooked contaminated meat and has an incubation period
of 1 to 7 days. Severe abdominal distress is followed by fever and signs of septicemia. The
disease can take an oropharyngeal or abdominal form. Lesions at the base of the tongue, sore
throat, dysphagia, fever, and regional lymphadenopathy usually characterize involvement of the
oropharynx. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting, and
fever, followed by abdominal pain, hematemesis, and bloody diarrhea.
Diagnosis. The clinical evaluation of patients suspected of having inhalational anthrax should
include a chest radiograph and/or CT scan to evaluate for widened mediastinum and pleural
effusion. (Figure 4.1). For chest radiographs, see
http://phil.cdc.gov/PHIL_Images/02122002/00041/PHIL_1795_thumb.jpg and
http://phil.cdc.gov/PHIL_Images/02122002/00042/PHIL_1796_thumb.jpg.
Anthrax is not spread by person-to-person contact except in rare cases of transmission from
cutaneous lesions. If the history does not reveal possible environmental exposure, anthrax is not
a likely diagnosis. Depending on the clinical presentation, Gram stain and culture should be
performed on specimens of blood, pleural fluid, CSF, and tissue biopsy or discharge from
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