Acta Otolaryngol 2002; 122: 580 – 585 GUEST EDITORIAL Anthrax: What Should the Otolaryngologist Know? PATRICK J. BRADLEY 1 , ALFIO FERLITO 2 , MARGARET S. BRANDWEIN 3 , MICHAEL S. BENNINGER 4 and ALESSANDRA RINALDO 2 From the 1 Department of Otorhinolaryngolog y —Head and Neck Surgery, Queen’s Medical Centre, Nottingham, UK, 2 Department of Otolaryngology —Head and Neck Surgery, University of Udine, Udine, Italy, 3 Department of Pathology and Otolaryngolog y, Mount Sinai School of Medicine, New York, New York, USA, 4 Department of Otolaryngology —Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, USA Bradley PJ, Ferlito A, Brandwein MS, Benninger MS, Rinaldo A. Anthrax: what should the otolaryngologis t know? Acta Otolaryngol 2002; 122: 580–585. INTRODUCTION Bacillus anthracis can cause four forms of serious infection: (i) pulmonary anthrax, which is often fatal; (ii) cutaneous anthrax, which is usually curable with antibiotics; (iii) gastrointestinal anthrax, which can also be fatal; and (iv) oropharyngeal anthrax, which is the rarest form and milder than gastrointestinal anthrax (1). In the late 20th century, anthrax was relegated to the status of a medical curiosity. In the US, sporadic cases had been reported in the Midwest and West, due to the hyperendemic persistence of spores affecting the white-tailed deer, which overowed to livestock. In Europe, a signicant num- ber of human infections were reported in Spain, which were again believed to be related to hyperen- demic or livestock sources (2). However, following the tragedy of 11 September, 2001 in New York, the threat of anthrax as a biological weapon and possible agent of mass destruction has been actualized (3). In the 7 weeks following this tragedy, seven cases of inhalation anthrax (three fatal) and eight cases of cutaneous anthrax were reported in the US (4–8). As physicians our perception of anthrax has changed forever. Just as the AIDS epidemic represented a paradigm shift in the gamut of our differential diag- noses, so too has the diagnosis of anthrax shifted from the realm of the arcane to that of the possible. EPIDEMIOLOGY B. anthracis is distributed worldwide. All animals are susceptible to varying degrees but the disease is most prevalent among herbivores (cattle, sheep, horses, deer and goats). Anthrax therefore occurs in both domestic and wild animals. Human infections de- velop after contact with infected animals or contami- nated articles or animal products. Anthrax infection in herbivores tends to be severe, with a high mortality rate. Terminally ill animals tend to bleed from the nose, mouth and bowel, thereby contaminating soil or water with B. anthracis , which can subsequently sporulate and persist in the environment. Studies of agricultural outbreaks suggest that conditions for multiplication are favorable when the soil pH is \6.0 and the soil is rich in organic matter. Major changes in the soil microenvironment, such as drought or rainfall, enhance sporulation. Aggressive animal vaccination programs have lowered the preva- lence of anthrax among livestock. However, it re- mains problematic in some developing parts of Asia and Africa where vaccination programs are sporadic. In the US, the microorganism remains endemic in the soils of Texas, Oklahoma, South Dakota, Arkansas, Louisiana, Mississippi and California (2, 9); however, naturally occurring infections in these endemic areas are extraordinarily rare. Most cases in industrialized countries are associated with exposure to animal products, especially goat hair imported from Turkey, Sudan and Pakistan, where anthrax remains common among domestic livestock (2). The majority of human cases of anthrax are due to exposure to spores from either agricultural or industrial sources. Spore formation is necessary for infection. The B. anthracis capsule is resistant to macrophage phago- cytic defenses, and hence the spores can germinate and multiply within macrophages after host exposure. Non-encapsulated variants of B. anthracis are non- virulent. There have been no reported cases of direct human –human transmission of inhalation anthrax, which relates to the necessity for sporulation (10). Only two cases of cutaneous anthrax arising from direct contact with other cutaneous cases have been reported. Transmission has also been reported after contact with contaminated dressings from a case of cutaneous anthrax. This nding conrms that caregivers should institute precautions to protect against secretions. The bloody sputum which occurs with inhalation anthrax should also be considered as infectious (11). Shepherds, farmers and workers in manufacturing plants using infected animal products, © 2002 Taylor & Francis. ISSN 0001-6489