Anthrax of the skinA22.0

A notifiable zoonosis with Bacillus anthracis, which occurs very rarely in humans and is widespread worldwide. The disease anthrax manifests itself in 4 main forms:

• Skin anthrax (incubation period hours to days after cutaneous inoculation of the germs)
• Pulmonary anthrax (incubation period 4-6 days after inhalation of the germs)
• Gastrointestinal anthrax (incubation period 1-3 days after oral uptake of the germs)
• Injection anthrax (incubation time 1-3 days after injection of the germ-containing material)

Bacillus anthracis (large gram-positive rod; width: 1-2 μm; length: 3-10 μm; toxin-forming agent).

Infection through contact with spores of the pathogen Bacillus anthracis from contaminated animal materials (organs, fur, wool, fertiliser with bone meal). The spores are extremely resistant and can survive for years in animal products or in the animal environment (pastures, stables, feed). After inoculation of the spores (skin injury, inhalation or consumption) the growth of the pathogen begins and a protein capsule is formed which protects it from phagocytosis. It also produces various exotoxins (lethal toxin, edema toxin).

Mostly work-related infection among others in agricultural workers, butchers, leather workers, furriers.

Mostly cutaneous manifestation (95%), more rarely pulmonary anthrax after inhalation inoculation (5%) or intestinal anthrax after oral uptake of spores (< 1%).

Incubation period: hours to 6 days.

Cutaneous anthrax: pathogen entry occurs into the skin through a small lesion. At the site of inoculation, development of a less conspicuous red spot: increasing infiltration with then rapid formation of an inflammatory nodule or pustule (pustula maligna).

Rapid growth with hemorrhagic blistering. Formation of a blackish necrosis with significant collateral swelling, highly inflammatory gelatinous infiltrate, and satellite vesicles. This clinical finding is also referred to as"splenic gangrene".

Important: in contrast to a furuncle caused by staphlococci, the splenic gangrene carbuncle is usually not painful or only slightly painful! (Note: the lack of pain distinguishes the splenic gangrene from a staphlogenic abscess!). Characteristic are early appearing mild regional lymphangitis and lymphadenitis, but also dullness, malaise, headache with varying high and also high febrile temperatures. Danger of sepsis. After 7-10 days the symptoms disappear. The complete healing of the splenic gangrene can take weeks. In rare cases: secondary infections.

Pulmonaryanthrax (anthrax pneumonia): after inhalation of dust containing spores, development of severe bronchopneumonia with high fever within a few days. If untreated, sepsis with fatal outcome after 2-3 days.

Intestinal anthrax (very rare): after consumption of infected meat.

Injection anthrax (increasingly common): severe soft tissue infection that can occur in injecting drug users.

The decisive factor is a possible exposure in the anamnesis if the clinic is appropriate.

Detection of the pathogen in the smear preparation of the skin lesion ( Gram stain) or in culturally in special laboratories (skin lesion, sputum, stool, blood). If necessary 16S rRNA- PCR and gene sequencing.

Cave! Due to the danger of generalization, surgical manipulation (biopsies) should be avoided in cases of anthrax carbuncles.

Early use of penicillin G in a medium dosage (2-4 million IU/day i.v.) to prevent dissemination of the pathogens. In severe cases or generalisation short infusion of penicillin G 2-4 times/day 10 million IU, then reduction of the dose to 2 million IU/day for 14 days.

Alternatively: Ciprofloxacin (e.g. Ciprobay) 2 times/day 400 mg i.v. or Tetracycline (e.g. Achromycin) 3-4 times/day 0.5-1.0 g p.o. or Erythromycin (e.g. Erythrocin) 3-4 times/day 250-500 mg i.v. or p.o.

Misuse as a biological terrorist weapon in the USA (see also anthrax pneumonia)

1. Bartlett JG et al (2002) Management of anthrax. Clin Infect Dis 35: 851-858.
2. Brook I (2002) The prophylaxis and treatment of anthrax. Int J Antimicrob Agents 20: 320-325.
3. Denk A et al.(2015) Cutaneous anthrax: evaluation of 28 cases in the Eastern Anatolian region of
4. Turkey.Cutan Ocul Toxicol. 2015 Jul 30:1-4. [Epub ahead of print].
5. Koch R (1876) The aetiology of anthrax disease, founded on the evolutionary history of Bacillus anthracis. Contributions to the biology of plants 2: 277-310.
6. Lawn SD et al (2003) A black necrotic ulcer. Lancet 361: 1518
7. McGovern TW, Norton SA (2002) Recognition and management of anthrax. N Engl J Med 346: 943-945.
8. Pasteur L, Chamberlain CE, Roux E (1881) Compte rendu sommaire des experiences faites a Pouilly-le-Fort, pres Melun, sur la vaccination charbonneuse. Comptes Rendus des seances De LíAcademie des Sciences 92: 1378-1383.
9. Prince AS (2003) The host response to anthrax lethal toxin: unexpected observations. J Clin Invest 112: 656-658
10. Spencer RC (2003) Bacillus anthracis. J Clin Pathol 56: 182-187
11. Sweeney DA et al (2011) Anthrax infection. Am J Respir Crit Care Med 184:1333-1341.

12. Tartar AS et al (2021) Severe bullous cutaneous anthrax with malignant edema. Rev Soc Bras Med Trop 54:e0164.

13. Tutrone WD et al (2002) Cutaneous anthrax: a concise review. Cutis 69: 27-33