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Reports Show How Anthrax Threw Doctors

Details of first fatality cases reveal physicians didn't initially know what they were dealing with

FRIDAY, Nov. 9, 2001 (HealthDayNews) -- Case details on the first two men to die in the anthrax outbreak reveal how unfamiliar doctors are with the biological weapon: In the first case, they initially thought they were dealing with meningitis; in the second, they gave the patient an antacid at the outset, thinking he had a stomach virus.

Part of the problem, the reports show, is that the victims waited until they were very ill before seeking medical attention. And by the time the scrambling doctors knew they were dealing with inhalation anthrax, it was too late to save them.

The four people who have died of inhalation anthrax since the attacks-by-mail began more than a month ago "presented to medical attention with more critical illness than those that survived," says Dr. Bradley Perkins, chief of the meningitis and special pathogens branch at the Centers for Disease Control and Prevention.

Doctors learned from the cases that lung, or inhaled, anthrax acts somewhat like a train: It gets off to a slumbering start, mimicking other illnesses. But once it starts chugging along, it is almost unstoppable. They also learned to treat people in outbreak areas as if they have anthrax, even while waiting for the full diagnosis.

On Oct. 5, Bob Stevens, 63, became the first person to die from lung anthrax in what America soon learned was more than a random encounter with the killer germ.

According to a report rushed to publication on the Web site of the New England Journal of Medicine, Stevens, a photo editor at a Florida tabloid newspaper, was brought to the hospital on Oct. 2 by his wife after he awoke feverish, confused and vomiting. He had no other symptoms of flu or flu-related syndromes, like a sore throat or runny nose, and doctors at first believed he might have contracted bacterial meningitis.

A chest X-ray revealed that Stevens had an abnormally wide mediastinum, the area between the lungs and the breastbone, and a test of his spinal fluid turned up both blood cells and bacteria -- prompting his doctors to consider anthrax. That hunch was tentatively confirmed 24 hours later by hospital lab workers, and nailed down later by Florida health officials.

In the meantime, Stevens was being treated with large doses of penicillin, but was getting worse. He had suffered a seizure shortly after being admitted to the hospital, and his fever remained high, at one point reaching 104° Fahrenheit. On Oct. 5, his heart stopped beating and he died. He was the first lung anthrax fatality in the United States since 1976, but not the last.

On Oct. 21, the second patient who would die from inhalation anthrax was at a hospital emergency room after suffering a brief blackout at church. Joseph Curseen, a Washington, D.C.-area postal worker, told doctors he had been ill for five days.

Doctors initially suspected that he'd been stricken with a gastrointestinal virus and they gave him the antacid Pepcid and other drugs to soothe his stomach. An hour and 15 minutes later, Curseen declared that his nausea was gone, he said he "felt much better," and he was sent home.

"His gastrointestinal symptoms and hypotension were thought to be related to a gastrointestinal illness of viral origin," says a report on Curseen's case in an electronic version of the journal Clinical Infectious Diseases.

But in barely a day's time, Curseen, 47, returned to the hospital, this time in an ambulance, complaining of three more blackouts. He had a fever, rapid pulse and labored breathing.

Realizing at this point they were dealing with a massive infection, physicians started him on intravenous infusions of three antibiotics, including Cipro and penicillin. Curseen died on Oct. 22 after his heart stopped. The Centers for Disease Control and Prevention later confirmed that the source of his death was anthrax.

The report on Curseen says he probably would not have survived even if he had been treated for anthrax on his first hospital visit, because the disease had gained such a foothold.

Taken together, the two case reports offer clinicians detailed but somewhat different pictures of inhalation anthrax at work, and they point up the hurdles to making an accurate diagnosis quickly enough to save a life.

They also raise the crucial question: Why did most of the patients with serious anthrax survive their disease?

"In general, the persons that did poorly and died presented to medical attention with more critical illness than those that survived, suggesting that early identification and prompt treatment was important to the increased survival rate [compared with earlier anthrax outbreaks] that we saw," says Perkins, who is leading the investigation for the CDC.

The CDC says it has identified 17 confirmed and 5 suspected cases of anthrax, including the four deaths. Twelve of those cases involve the skin form of the infection, while 10 are inhalation disease, anthrax's gravest incarnation and the type that caused the fatalities.

All but one of the cases and deaths have been linked to contaminated mail, and have involved postal and media employees who handled the letters. The only exception is Kathy Nguyen, a 61-year-old Manhattan hospital worker, who died Oct. 31 after contracting lung anthrax. Officials have so far been frustrated in their efforts to pin down the source of her infection.

Perkins says his agency's own review of the 10 confirmed and suspected inhalation cases shows some similarities, but also differences. The average victim was male (because of a predominately male postal service workforce) and 56 years old. That's slightly older than expected, but age is so far not a known risk factor.

One thing for certain emerges from the case reports, experts say. Patients will die unless they receive ample antibiotics and support care before the infection overwhelms them.

What To Do

For the government's latest news on anthrax, try the Centers for Disease Control and Prevention.

To learn more about the microbe, try the University of Wisconsin.

And for more on why anthrax is considered such an effective bioterrorism weapon, try the U.S. Department of Defense.

SOURCES: Teleconference with Bradley Perkins, M.D., Centers for Disease Control and Prevention, Atlanta; Nov. 29, 2001, New England Journal of Medicine; Nov. 6, 2001, Clinical Infectious Diseases
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