Bacillus anthracis meningitis during an outbreak of injectional anthrax, Scotland, UK

Abstract

We read with interest the article by Wurtz et al. [1] concerning the negative impact of laws regarding biosecurity and bioterrorism on real diseases. As the article states, ‘The actual number of known victims and fatalities caused by the intentional use of microorganisms has been negligible as compared with those caused by naturally acquired human infections.’ This is indeed true of Bacillus anthracis, with anthrax infection most commonly community acquired than associated with bioterrorism. It seems prudent, therefore, to understand how this disease naturally presents. For instance, a new form of cutaneous anthrax has been recently recognized in injecting drug users and named injectional anthrax. We present three cases of injectional anthrax that offer a unique insight into the rare entity B. anthracis meningitis. Meningitis due to infection with B. anthracis is considered a rare manifestation of anthrax, with just over 100 reported cases in the world literature, but it is associated with high mortality, as it is nearly always fatal [2]. Also, injectional anthrax can be a challenge for clinicians to recognize as a result of its unfamiliar and atypical presentation. The typical sign of cutaneous anthrax—a black-crusted painless lesion, known as an eschar— is not normally found [3]. An outbreak of injectional anthrax occurred in injection drug users in Scotland during 2009–2010 that was linked to the use of contaminated heroin [4]. Out of 119 cases, 47 were laboratory confirmed, and 13 of these confirmed cases were fatal [3]. Three cases of death were attributed to anthrax meningitis at postmortem examination,