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
Ezzell JW Jr, Abshire TG. Immunological analysis of
cell-associated
antigens of Bacillus anthracis. Infect Immun 1988;56:349-56.
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.
Brachman PS. Anthrax. In: Eickhoff TC, ed. Practice of medicine.
Vol
III. Hagerstown, Maryland: Harper and Row, 1978.
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