Abstract
Bacillus anthracis infection (anthrax) has three distinct clinical presentations depending on the route of exposure: cutaneous, gastrointestinal and inhalational anthrax. Each of these can lead to secondary bacteraemia and anthrax meningitis. Since 2009,anthrax has emerged among heroin users in Europe,presenting a novel clinical manifestation, 'injectional anthrax', which has been attributed to contaminated heroin distributed throughout Europe; before 2009 only one case was reported. During 2012 and 2013,new cases of injectional anthrax were diagnosed in Denmark, France, Germany, and the United Kingdom.Here we present a comprehensive review of the literature and information derived from different reporting systems until 31 December 2013. Overall 70 confirmed cases were reported, with 26 fatalities (37% case fatality rate).The latest two confirmed cases occurred in March 2013. Thirteen case reports have been published,describing 18 confirmed cases. Sixteen of these presented as a severe soft tissue infection that differed clinically from cutaneous anthrax, lacked the characteristic epidemiological history of animal contact and ten cases required complimentary surgical debridement. These unfamiliar characteristics have led to delays of three to 12 days in diagnosis, inadequate treatment and a high fatality rate. Clinicians' awareness of this recently described clinical entity is key for early 'and successful management of patients.
Highlights
Anthrax is a worldwide endemic zoonotic disease, of herbivores, caused by the bacterium Bacillus anthracis, a Gram-positive rod
A total of 70 laboratory-confirmed cases of injectional anthrax were reported among heroin users in Europe [4,6,8-11;14-26]
Injecting drug users (IDUs) are at higher risk of developing diverse forms of infections, among those, soft tissue infection is a well-known complication of parenteral drug use, though anthrax infection of injection sites was considered very rare before the 2009−2010 injectional anthrax outbreak [30,31]
Summary
Anthrax is a worldwide endemic zoonotic disease, of herbivores, caused by the bacterium Bacillus anthracis, a Gram-positive rod. The infective form is usually the spore, a stable form that can survive in certain environments for decades [1]. The spores may infect the host through different routes and lead to a variety of clinical presentations depending on their route of entrance: cutaneous (the most common form of infection), gastrointestinal and inhalational anthrax. Complications of these three infections are secondary bacteraemia and anthrax meningitis. Once the spores have penetrated the skin or mucosa, they germinate to the vegetative bacteria, which proliferate and produce the virulence factors, two exotoxins − lethal toxin and edema toxin −, causing the characteristic pathological findings: edema, haemorrhage and tissue necrosis with a relative lack of leukocytes in infected tissues [1,2]
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