|Year : 1991 | Volume
| Issue : 1 | Page : 38-40
Cutaneous anthrax with secondary infection
SM Sridhar, P Chandrashekhar, J
S M Sridhar
Source of Support: None, Conflict of Interest: None
A case of cutaneous anthrax with pus formation and with pain and tenderness in local lesion is reported. The lesion appeared 40 days after handling of anthrax-infected animal. The lesion was fairly large and irregular. The patient was treated with oral chloramphenicol and the lesion healed in about 60 days.
Keywords: Cutaneous anthrax, Secondary infection, Chloramphenicol
|How to cite this article:|
Sridhar S M, Chandrashekhar P, J. Cutaneous anthrax with secondary infection. Indian J Dermatol Venereol Leprol 1991;57:38-40
|How to cite this URL:|
Sridhar S M, Chandrashekhar P, J. Cutaneous anthrax with secondary infection. Indian J Dermatol Venereol Leprol [serial online] 1991 [cited 2020 Jun 3];57:38-40. Available from: http://www.ijdvl.com/text.asp?1991/57/1/38/3618
Cutaneous anthrax usually appears in the form of a localised, painless, central black eschar with surrounding oedema. This is also called `malignant pustule' even though it is neither malignant nor pustular.
Unlike a boil pus is never present in anthrax. , Absence of pus is considered to be an important feature of cutaneous anthrax., Similarly absence of pain and tenderness in lesion itself is also considered a feature of anthrax. , However, pus and/or pain and tenderness may be present if the lesion is secondarily infected, which is a rare phenomenon in this disease. ,,,
We encountered a patient in whom the cutaneous lesion due to anthrax infection was both painful and showed evidence of suppuration.
| Case Report|| |
A male patient aged 26 years presented with a sore on the dorsum of right hand of 2 days duration. The complaint started as malaise, fever and headache. on the second day he noticed a scald like lesion on the dorsum of right hand. By third day ulcer formation with haemorrhagic areas could be seen. He gave history of handling sick cattle and sheep, 40 days earlier. There was also history of ingestion of meat of two of these animals. Blood smears of these dead animals were positive for anthrax bacilli. History of attending patients with anthrax 20 days earlier is present. 
Patient's vital data was normal. Local examination showed an ulcer of 5 cm X 4 cm on the dorsum of right hand. [Figure - 1] Small vesicular satellite lesions were present, extending onto the dorsum of index finger. The floor of the ulcer was dry, parchment like and dark in colour. Black area was seen in the middle. Serous discharge on firm pressure was noticed. There was oedema of dorsum of hand which was not pitting in nature. The lesion was not painful to start with. On the 3rd day he developed pain and tenderness. There was no lymph node enlargement. Systemic examination revealed nothing of note.
His blood total leukocyte count was 4000/ cmm with differential count of N70 L 28 E 2 and E.S.R. of 6 mm/1st hour. Serous exudate obtained by pressing ulcer base was cultured for microorganisms and was studied microscopically also. Gram stained smears showed Gram positive rods suggestive of anthrax. Bacillus Anthracis, coagulase positive Staphylococci and Klebsiella were grown in culture. Since all the three organisms were sensitive to chloramphenicol and as the patient was allergic to penicillin, he was prescribed cap. chloramphenicol 500 mg 6 hourly and the lesion was covered with a sterile dressing. He was subsequently followed up at his residence in his village. He applied some ointment in addition to getting his bandage renewed every day. On the 8th day the lesion showed pus as well as necrotic tissue and some red granulation tissue. The lesion looked like any other non specific ulcer with pus. He continued to take chloramphenicol and vitamins for further period of one week. He was seen again on 32nd day by which time, the ulcer was healing and a greenish scab was still present over the part of lesion. There was no pain and tenderness.
By 66th day the lesion healed completely leaving depigmented scar with purplish margin. [Figure - 2]
| Comments|| |
The general view is that cutaneous anthrax should be considered in all patients who have painless ulcers associated with vesicles and edema and history of contact with animal products or animals.  Once the diagnosis of cutaneous anthrax is suspected, the recognition and diagnosis is easy. ; Though the classical view is that pus and pain are very rare, their presence alone will not exclude the diagnosis. When secondary infection results in pus and slough formation, the characteristic black eschar formation may get masked and the lesion may appear like an ordinary infected ulcer, as in the case reported here. In one of the cases of Ellingson et al penicillin resistant Staphylococcus aureus was cultured from the lesion along with B.anthracis 24 hours after treatment had been initiated.  In one of Taylor and Carslaw's cases a light growth of Staphylococcus albus and coliform organisms was obtained.  In the case reported here penicillin resistant coagulase positive Staphylococcus aureus and Klebsiella were grown before initiation of treatment with chloramphenicol. Turner suggests that the organism B. anthracis appears not to be sensitive to chloramphenicol.  That may be the reason why the lesion took about 8 weeks to heal in the case reported. Slow resolution of the lesion in 2 to 6 weeks is described even without treatment.  Spontaneous healing in 80-90% of the cases is also described.  In the case reported depigmented scar of pinkish hue with purplish margin was all that was left behind after healing.
Though the incubation period of anthrax is 3-10 days,  the lesion appeared in the patient nearly 40 days after handling the sick animals, raising the possibility of spread from other patients. The lesion in the patients was fairly large and irregular in shape as is rarely described 
| References|| |
|1.||Christie AB : Infectious Disease - Epidemiology and Clinical Practice, 3rd ed., Churchill Livingstone, Edinburgh, 1980; p 703-721. |
|2.||Knudson GB : Treatment of Anthrax in Man : History and Current Concepts, Military Med, 1986; 151 : 71-77. |
|3.||Taylor L and Carslaw RW : Cutaneous Anthrax, Lancet, 1967; i : 1214-1216. |
|4.||Turner M : Anthrax in Humans in Zimbabwe, Central Afr J of Med, 1980; 26 : 160-161. |
|5.||Brachman PS : Anthrax, in :Cecil text book of medicine, Eighteenth ed, Editors, Wyngaarden JB and Smith LH Jr: W.B. Saunders Company, Philadelphia, 1988; p 1667-1668. |
|6.||Ellingson HV, Kadull PJ and Bookwalter HL : Cutaneous Anthrax - Report of Twenty-Five cases, J Amer Med Assoc, 1946; 131 : 1105-108. |
|7.||Freedman ML and Thorpe MEC : Anthrax : A case Report And A Short Review of Anthrax in Australia. Med J of Austr, 1969; 1 : 154-157. |
|8.||Christie AB : The clinical aspects of anthrax, Postgrad Med J, 1973; 49 : 565-570. |
|9.||Chandrasekhar P, Jaya Singh, RS, Sridhar MS et al : Outbreak of human anthrax n Ramabhadrapuram village of Chittoor District in Andhra Pradesh, Ind J Med Res, November 1990 (Accepted). |
|10.||Holmes RK : Anthrax, in : Harrison's Principles of internal medicine, Twelfth ed, Editors, Wilson JD, Braunwald E, Isselbacher KJ et al : Mc Graw-Hill Book Company, New York, 1991; p 575-577. |
[Figure - 1], [Figure - 2]
|This article has been cited by|
|| mini outbreak of cutaneous anthrax in Vizianagaram district, Andhra Pradesh, India
| ||Rao, T.N., Venkatachalam, K., Ahmed, K., Padmaja, I.J., Bharthi, M., Rao, P.A. |
| ||Indian Journal of Dermatology, Venereology and Leprology. 2009; 75(4): 416-418 |
||An outbreak of cutaneous anthrax in a non-endemic district - Visakhapatnam in Andhra Pradesh
| ||Rao, G.R.R., Padmaja, J., Lalitha, M.K., Rao, P.V.K., Gopal, K.V.T., Kumar, H.K.Y., Mohanraj, P. |
| ||Indian Journal of Dermatology, Venereology and Leprology. 2005; 71(2): 102-105 |