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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 49-53

An outbreak of cutaneous anthrax in a tribal area of Visakhapatnam district, Andhra Pradesh


Department of DVL, Andhra Medical College, King George Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication22-Mar-2018

Correspondence Address:
Dr. B Balachandrudu
Department of DVL, Andhra Medical College, King George Hospital, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_81_17

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  Abstract 


Background: Anthrax is a disease of herbivorous animals, caused by Bacillus anthracis and humans incidentally acquire the disease by handling infected animals and their products. Though the disease has become rare, endemic outbreaks occur in tropical countries, where veterinary control of livestock is marginal and environmental conditions favor an animal-soil-animal cycle.
Materials and Methods: Eight tribal men from Kodipunjuvalasa village of Araku valley presented with painless ulcers associated with vesiculation and edema of surrounding skin on upper limbs without any constitutional symptoms. There was a history of slaughtering and consumption of cooked meat of sick goat 1 week to 10 days prior to the development of skin lesions. Cutaneous anthrax was suspected and smears, swabs were taken for culture and polymerase chain reaction (PCR). All the cases were treated with intravenous followed by oral antibiotics. Appropriate health authorities were alerted and proper control measures were employed.
Results: Smears from the cutaneous lesions were positive for Bacillus anthracis in all our cases and this was confirmed by a positive culture and PCR of smears. All the cases responded to antibiotics.
Conclusion: We report eight cases of cutaneous anthrax in tribal area of non-endemic district, Visakhapatnam, Andhra Pradesh.

Keywords: Cutaneous anthrax, painless ulcers, tribal


How to cite this article:
Balachandrudu B, Amrutha Bindu S S, Kumar CN, Malakondaiah P. An outbreak of cutaneous anthrax in a tribal area of Visakhapatnam district, Andhra Pradesh. J NTR Univ Health Sci 2018;7:49-53

How to cite this URL:
Balachandrudu B, Amrutha Bindu S S, Kumar CN, Malakondaiah P. An outbreak of cutaneous anthrax in a tribal area of Visakhapatnam district, Andhra Pradesh. J NTR Univ Health Sci [serial online] 2018 [cited 2020 Mar 29];7:49-53. Available from: http://www.jdrntruhs.org/text.asp?2018/7/1/49/228153




  Introduction Top


Anthrax is a disease of herbivorous animals caused by Bacillus anthracis and humans incidentally acquire infection by direct inoculation of spores through breaks in the skin (cutaneous anthrax), by inhalation of spores (pulmonary anthrax), or by ingestion of contaminated meat (gastrointestinal anthrax).[1],[2],[3] Cutaneous anthrax is the commonest type. Sporadic cases of cutaneous anthrax caused by biting flies have been reported.[4],[5]

Anthrax is known to occur globally and it has been estimated that as many as 20,000–1,00,000 human cases of anthrax occur annually generally in underdeveloped regions of the world, where livestock are not vaccinated.[1],[6] The actual incidence of anthrax in India is not known accurately due to the fact that a large number of cases go unreported and only a fraction of human cases receive medical attention in a hospital. Cases treated on site in a village are hardly brought to the notice of authorities. Hence, the incidence of anthrax in man is likely to be higher than reported in literature.

The detailed information collected from Southern Indian states, confirmed the endemicity of anthrax in Andhra Pradesh, Tamil Nadu, and Karnataka. In Andhra Pradesh, Chittoor, Kadapa, Guntur, Prakasam, and Nellore Districts are the known endemic areas for animal and human anthrax.[7],[8] There are reports of occurrence of cutaneous anthrax in five tribal men of Pedalabudu, Araku valley situated about 140 km from Visakhapatnam, which is a nonendemic district, in 2005.[9] Thirty six cases of human cutaneous anthrax were reported from tribal hamlets like Panasapottu, Goyyagunta, Vennelakota, in Araku valley of Visakhapatnam district, in 2016.[10]

Symptoms suggestive of cutaneous anthrax were identified in eight tribal men from Kodipunjuvalasa village of Araku valley, Visakhapatnam district. These cases prompted us to take up detailed study.


  Materials and Methods Top


Eight men were brought with painless ulcers with surrounding vesiculation and edema on the upper extremities, few were with black eschar in the center of the lesion, and few were with associated axillary lymphadenopathy [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4]. They had no constitutional symptoms. Three weeks earlier, they noticed one of their goats was sick and these people were involved in slaughtering, cooking, and eating the meat of that animal. They started developing the skin lesions 1 week to 10 days after handling the animal.
Table 1: Clinical details of cutaneous anthrax patients

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Figure 1: Ulcerative plaque with eschar over ventral aspect of right foream

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Figure 2: Painless ulcer with edema over dorsal aspect of left little finger

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Figure 3: Edema of left hand with bullae & eschar

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Figure 4: Painless ulcer with eschar over dorsal aspect of left forearm

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On the basis of characteristic clinical manifestations and history of contact with an infected animal, a clinical diagnosis of cutaneous anthrax was made. All patient were hospitalized, isolated, and investigated. Smears and swabs were taken from the vesicles, ulcers, and they were Gram stained and cultured. Routine blood and biochemical investigations and chest X-ray were done in all cases.

All the patients were treated with intravenous ciprofloxacin 200 mg 12th hourly and oral doxycycline 100 mg 12th hourly for 10–14 days. They were advised to follow-up with oral ciprofloxacin 500 mg BD and oral doxycycline 100 mg BD for 60 days.


  Results Top


Smears from skin lesions of all suspected cases revealed Gram positive bacilli arranged singly or in short chains [Figure 5]. On agar plates, round colonies are formed which are opaque, greyish white with a frosted glass appearance [Figure 6]. These findings are suggestive of Bacillus anthracis.
Figure 5: Gram positive bacilli arranged in chains

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Figure 6: Round , opaque , greyish white colonies on blood agar

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Prompt clinical response to ciprofloxacin and doxycycline therapy was seen in all our patients, with improvement in the form of reduction of surrounding edema and healing of cutaneous ulcer within a period of 7–10 days [Figure 7].
Figure 7: Response to antibiotic treatment after 1 week

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  Discussion Top


Anthrax is a zoonosis caused by Bacillus anthracis. It was the first pathogenic bacterium to be observed under microscope (Pollender, 1849), the first communicable disease shown to be transmitted by inoculation of infected blood (Davaine, 1850), the first bacillus to be isolated in pure culture and shown to possess spores (Koch, 1876) and the first bacterium used for preparation of attenuated vaccine (Pasteur, 1881).

Anthrax bacillus is Gram positive, nonacid fast, nonmotile, brick-shaped, measuring about 3–10 μm × 1-1.6 μm. In tissues, it is found singly, in pairs or in short chains, the entire chain being surrounded by capsule. The capsule is polypeptide in nature. Chain of bacilli in cultures presents bamboo stick appearance. With polychrome methylene blue staining, amorphous purplish material is noticed around the bacilli under microscope. This represents capsular material and is characteristic of anthrax bacillus. This is called the M'Fadyean reaction and it is used for presumptive diagnosis of anthrax in animals. On agar plates, irregularly round colonies are formed, 2–3 mm in diameter, raised, dull, opaque, greyish white with a frosted glass appearance. Under low power microscope, the edge of the colony is composed of long interlacing chains of bacilli, resembling locks of matted hair giving “Medusa head appearance”. The spores are formed in culture or in the soil, but never in animal body during life. Oxygen is required for sporulation and spores are ubiquitous and they are highly resistant to physical and chemical agents.

In nature, anthrax is primarily a disease of cattle and sheep, and less often of horses and swine but experimentally most animals are susceptible to a greater or lesser degree. Animals are infected by ingestion of the spores present in the soil. Direct spread from animal to animal is rare. Infected animals shed large numbers of bacilli, in the discharges from the mouth, nose, and rectum, which sporulate in soil and remain as the source of infection. Humans acquire infection from animals incidentally. Human anthrax may be industrial or nonindustrial. Industrial anthrax is found in workers in industries such as meat packing or wool factories. Nonindustrial anthrax is often an occupational disease in those who associate frequently with animals, such as veterinarians, butchers, and farmers.

Human anthrax may be: (1) Cutaneous (2) Pulmonary, or (3) Intestinal, among which cutaneous anthrax is common. Cutaneous anthrax follows entry of infection through the skin. The face, neck, hands, arms, and back are the usual sites. The lesion starts as a papule 1–3 days after the infection and becomes vesicular, containing fluid which may be clear or blood stained. The whole area is congested and edematous, and several satellite lesions filled with serum or yellow fluid are arranged around a central necrotic lesion which is covered by a black eschar. The name Anthrax, which means coal, comes from the black color of the eschar. The lesion is called malignant pustule. Cutaneous anthrax generally resolves spontaneously, but 10–20% of untreated patients may develop fatal septicemia or meningitis.

The lesion most commonly confused with cutaneous anthrax is vaccinia, which no longer exists. Milker's nodules contracted from the teats of the cow are characterized by one or several brownish red dome shaped smooth or slightly papillomatous vegetation (resemble pyogenic granulomas), which are generally confined to the hands and forearms. Orf (ecthyma contagiosum) is a skin disease found usually in slaughterers or shepherds who may be in contact with sheep suffering from ecthyma contagiosum. It is of viral etiology and the appearance is more ragged and angry looking compared to the malignant pustule of anthrax. Moreover, Orf lacks the characteristic central eschar. Malignant pustule can be confused with a boil, but a Gram-stained smear of exudate is confirmatory. A painful pustular eschar in a febrile patient indicates a secondary infection, most often with staphylococcus or streptococcus.[1],[2]

The following clinical features if present are strongly suggestive of cutaneous anthrax:[1],[2]

  1. The presence of edema out of proportion to the size of the lesion
  2. Lack of pain during initial phases of the infection
  3. The rarity of polymorphonuclear leukocytes from vesicular fluid or Gram stain.


Anthrax may be diagnosed by microscopy, culture, animal inoculation, and serological demonstration of the anthrax antigen in infected tissues. When an animal is suspected to have died of anthrax, autopsy is not permissible, as the split blood will lead to contamination of the soil. An ear may be cut off from the carcass and sent to the laboratory. Alternatively, swabs soaked in blood or several blood smears may be sent.

Antibiotic therapy is effective in human cases of anthrax, but rarely succeeds in animals as therapy is not started sufficiently early. Antibiotics have no effect on the toxin once it is formed. Penicillin and streptomycin are no longer used for treatment. They have been replaced by Ciprofloxacin and doxycycline, which are effective in prophylaxis and treatment. Spores are present in the body of infected individuals and they may get activated and release toxins for a period of 60 days. Hence, antibiotics are given for a period of 60 days.

Vaccines against anthrax for use in livestock and humans have had a prominent place in history of medicine. Louis Pasteur developed the first effective vaccine in 1881. Currently administered human anthrax vaccines include acellular and live spore varieties. The American product, Bio Thax, is licensed by FDA and was formerly administered in a six dose series at 0, 2, 4 weeks and 6, 12, 18 months with annual boosters to maintain immunity. In 2008, the FDA approved omitting the week 2 dose, resulting in the currently recommended five dose series. New second generation vaccines currently being researched include recombinant live vaccines and recombinant subunit vaccines.

Most animal vaccines for anthrax in use around the world utilize the toxigenic, noncapsulating B. anthracis strain 34F2. The protection offered by single dose of vaccine is said to last about 1 year, therefore annual boosters are recommended for livestock in epidemic areas.


  Conclusion Top


Anthrax is a disease of public health importance and a notifiable disease. Once the diagnosis is established in our cases, the district health authorities and animal husbandry personnel were informed. Specialist teams visited the affected and the surrounding villages for door-to-door surveillance and for conducting medical camps to detect new cases. Health education camps were conducted to educate the people about the handling of dead animals and also proper disposal of carcass by using lime. In the affected and surrounding villages, sanitary measures were taken up and the soil was decontaminated with bleaching powder.

Dermatologists play a crucial role in the diagnosis of naturally occurring cutaneous anthrax and also in the event of bioterrorism. The purpose of this report is to create awareness about cutaneous anthrax among dermatologists.

A disease of great antiquity, anthrax occupies an important place in the history of infectious diseases because it was the first human disease to be attributed to a specific pathogen. It has public health importance because of the potential for use of the bacillus spores in biological warfare.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Hanna P. Anthrax pathogenesis and host response. Curr Trop Microbiol Immunol 1998;225:13-35.  Back to cited text no. 3
    
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Turell MJ, Knudson GB. Mechanical transmission of bacillus anthracis by stable flies (Stomoxys calcitrans) and mosquitoes (Aedes aegypti and Aedes taeniorhynchus). Infect Immun 1987;55:1859-61.  Back to cited text no. 4
    
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Bradarić N, Punda-Polić V. Cutaneous anthrax due to penicillin-resistant Bacillus anthracis transmitted by an insect bite. Lancet 1992;340:306-7.  Back to cited text no. 5
    
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Sekhar PC, Singh RS, Sridhar MS, Bhaskar CJ, Rao YS. Outbreak of human anthrax in Ramabhadrapuram Village of Chittor District in Andhra Pradesh. Indian J Med Res 1990;91:448-52.  Back to cited text no. 7
    
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Sridhar SM, Chandrashekhar PJ. Cutaneous anthrax with secondary infection. Indian J Dermatol Venereol Leprol 1991;57:38-40.  Back to cited text no. 8
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Rao GR, Padmaja J, Lalitha MK, Rao PV, Gopal KV, Kumar HK, et al. An outbreak of cutaneous anthrax in a non-endemic district -- Visakhapatnam in Andhra Pradesh. Indian J Dermatol Venerol Leprol 2005;71:102-5.  Back to cited text no. 9
    
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Kumar GA, Raju BTVN, P, Vardhan KRH, P. Guru Prasad et al. An outbreak of cutaneous anthrax in tribal areas of visakhapatnam. J Evolution Med Dent Sci 2016;5:4378-81.DOI: 10.14260/jemds/2016/999.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Bioterrorism: Clinical and Public Health Aspects of Anthrax
Tulsi Chugh
Current Medicine Research and Practice. 2019;
[Pubmed] | [DOI]



 

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