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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by bboal on October 24, 2001, at 0:28:58
In September my scalp started itching badly and I had a small bump. I was given Alegra which didn't help and had no allergies turn up with a RAST test. Things progressed and my hair started breaking off and falling out. Within 5-7 days it turned to a blister. My doctor started treating me for a skin infection with Omnicef 300mg bid. I have been on it for 20 days now and the blister is now a small bump, but for the last 4 days I have been experiencing swollen and painful glands in my neck and armpits, difficulty breathing and I can not seem to stay awake (example: up at 9 am back in bed at ll, up at 3, in bed until 14 min ago and ready to sleep again). I really feel ill.
My doctor has ordered a Comp. Metabolic Panel, CBC with Diff, Lymes Profile, Sed Rate, Hep Profile ABC, Epson Barr virus testing, an MRI of the chest and abdomen to r/o Lymphoma, an appt. with a hematologist on 11/9 and a dermatologist on 11/13. I had sugessted a test for cutaneous anthrax and was brushed off. I can't honestly say there was ever any powder involved that I remember and anthrax has not shown up in Pennsylvania.
Maybe I am being paranoid but the symptoms sure are close to cutaneous anthrax. Would it show up in any of the tests that my doctor has ordered?
Thanks
Posted by KB on October 24, 2001, at 8:28:17
In reply to Could it be Anthrax?, posted by bboal on October 24, 2001, at 0:28:58
It's a specific test for Anthrax, but I don't think you need it - unless you're a postal worker or have some other specific risk. The number of anthrax cases compared to the US population is incredibly low, so the chances you would have it are also incredibly low.
Posted by stjames on October 24, 2001, at 10:34:35
In reply to Re: Could it be Anthrax?, posted by KB on October 24, 2001, at 8:28:17
It is very hard to get Anthrax.
James
Posted by Lini on October 24, 2001, at 12:39:09
In reply to Re: Could it be Anthrax?, posted by KB on October 24, 2001, at 8:28:17
Get tested for Anthrax. The difficulty breathing is not a symptom to play around about. Plus, even though the present cases of anthrax are statistically small, no one has any idea how widespread this bioterrorism will become. Postal workers listened to the CDC about their safety and ended up becoming sick and even dying. At the very least, it will be one less thing to worry about.
good luck!
Posted by Cam W. on October 24, 2001, at 20:23:04
In reply to Re: Could it be Anthrax?, posted by stjames on October 24, 2001, at 10:34:35
> It is very hard to get Anthrax.
>
> JamesJames - Even from an overseas pharmacy? ;^P
- Cam (sorry)
Posted by tina on October 24, 2001, at 20:38:04
In reply to Re: Could it be Anthrax? » stjames, posted by Cam W. on October 24, 2001, at 20:23:04
Better safe than sorry. Might as well get the test. It'll be a weight off your mind at the very least.
Posted by wendy b. on October 24, 2001, at 21:47:00
In reply to Re: Could it be Anthrax?, posted by tina on October 24, 2001, at 20:38:04
> Better safe than sorry. Might as well get the test. It'll be a weight off your mind at the very least.
Yes, it seems all they have to do is swab the nose & do the specific test for anthrax. Lini is right, we have no idea how widespread this is going to become. Anybody in the healthcare system who blows you off is an idiot. IMHO. The D.C. postal workers were sent home without being tested... and look what happened to them.
BBoal, what do you do for a living?
Wendy
Posted by Mitchell on October 24, 2001, at 22:25:26
In reply to Could it be Anthrax?, posted by bboal on October 24, 2001, at 0:28:58
The elements of your situation that indicate against coetaneous anthrax seem to be the secondary glandular involvement, even while on antibiotics, and the time of onset in relation to the spread of anthrax spores in recent criminal enterprises. The first reported cases resulted from letters addressed in late September.
However, information about the criminal enterprise is incomplete. The known scope of exposure has expanded each day since the first reported fatality. Most recently, USPS mail processing equipment shipped to a repair facility has been found to be contaminated with bacillus anthracis spores of < 10 microns. If exposed to these rare spores manufactured for use as weapons, it is easy for a person to become infected.
The few thousand spores needed to cause pulmonary anthrax infection are, together, smaller than a speck of dust. With the amount of anthrax now known to have been distributed, undiscovered secondary spread of spores sufficient to cause coetaneous anthrax can be assumed. A letter that laid against a weaponized piece of mail, or that passed through the same mail handling equipment could then carry the spores. For this reason, the US Postal Service is now encouraging everyone to wash their hands after handling mail.
In such an uncertain time as this, you are not at all paranoid to wonder whether you might have been exposed. Prophylactic use of antibiotics might be misguided, but prophylactic testing for anthrax exposure is your right. Not only is it important for your mental health, it could be important to everyone's health and safety if it in some way contributes to the investigation and containment of this criminal activity. If your doctor will not provide the test, contact your local health department. If your local health department refuses, contact your state health department. If that does not produce results, please contact a public forum, such as you have done here, or other more conventional media outlets.
Posted by bboal on October 25, 2001, at 0:21:01
In reply to Re: Could it be Anthrax?, posted by Mitchell on October 24, 2001, at 22:25:26
I wish to thank everyone who took the time to answer my post. I will be speaking with my doctor.
Cam, I have two jobs (when well). I own my own website designing company that does well and a little shop that does more eBay business than onsite business.
Posted by paxvox on October 26, 2001, at 16:48:44
In reply to Re: Could it be Anthrax?, posted by bboal on October 25, 2001, at 0:21:01
ANNNNNNHHHHHHHHT!
Wrong answers folks.
1 in 20 billion, that's your chance of getting an anthrax letter. If you are a USPS employee, as am I, and should you work in Washington or NYC, well...your chances change a bit. If you had anthrax with the symptoms you have decribed, you would already be dead. Anthrax, in its aerosolized form, especially the high-grade strain in Daschel's office, will kill you in 3-4 days w/o treatment.If you are worried still, get the Cipro, take it for 10 days.
We can't all be doing that, however, because a antibiotic-resistant mutation could develop, as it has in previously easily treated bacterial infections.
Don't panic, people!
Are you lined up for your flu shot because of the 20,000 people PROJECTED to die this flu season?
I'm sorry if I have offended anyone by this post, but I have dealt with hazmat for 20 years in the USPS, it was no big deal until now, you have NO IDEA what has ALWAYS been in your mail.
PAX
waiting for the mud-slingers
Posted by Mitchell on October 27, 2001, at 1:43:00
In reply to Re: Could it be Anthrax? » bboal, posted by paxvox on October 26, 2001, at 16:48:44
I agree that the cutaneous lesion described here is probably not anthrax infection, primarily because the risk profile does not match that of recent antrhax infections. The secondary symptom described here is anxiety over what might have caused the lesion. In an uncertain and dangerous time, accurate information delivered in a calm and balanced voice has proven to be a reliable means to relieve some anxiety and to prevent panic. Medication should be considered only after other concerns are discussed with a patient.
>1 in 20 billion, that's your chance of getting an anthrax letter.
The present concern is not necessarily receipt of an anthrax letter, but rather possible infection from an unknown source, perhaps by secondary contamination such as the workplace exposure that resulted in the deaths of two U.S. postal workers. But the odds of receiving an anthrax letter, if one letter has been delivered anywhere in the world, could be about 1 in 6 billion (the estimated current world population)
Confirmed letters have been reported at a U.S. Senate office, and at two New York publications. With three confirmed letters, the odds would be about 1 in 2 billion.
Since all three letters letter were confirmed in the United States, the odds of receiving a letter would be about 1 in 100 million. If we narrow the group of likely recipients to U.S. residents in eastern states, the odds get even higher. But if we estimate that all of the confirmed letters were sent to national figures, the odds, based on recent events, could be significantly lowered. But then if we used curve fitting to account for emerging use of anthrax as a weapon, the odds would be much higher, and might show trends that are truly cause for concern. The Centers for Disease Control say it is highly unlikely that the Daschle letter was the only biological weapon delivered to Washington D.C. through the U.S. mail.
The primary risk now during this biological attack, however, is not receipt of an anthrax letter. As of Oct. 26, 13 confirmed cases of anthrax had resulted in three deaths. None of the decedents had received a confirmed anthrax letter. Two were employees of mail handling facilities. Anthrax spores have now been identified in mail handling facilities at several sites in at least three states, and in facilities related to the Supreme Court, the White House, the CIA, the House of Representatives and several news networks. Three victims of pulmonary anthrax infections remained hospitalized and another was recovering as an outpatient. Six other cases involving cutaneous anthrax infections were being treated with antibiotics.
Based on that information, the odds of getting an infection could be estimated at about 1 in 30 million. But again, several factors mitigate. Based on recent events, the odds of dying in a terrorist attack in the United States this year are about 1 in 50,000. That is certainly less chance than the 1 in 6,000 odds of dying in an automobile crash, but it represents a significant increase over even the most recent highest risk year, 1995, when the odds of death by terrorism in the United States were closer to one in 2 million. To begin an accurate statistical analysis, we would also need to consider curve fitting to assess the emerging risk. But accurate statistical analysis is probably impossible because we lack sufficient data about terrorists' capabilities or intentions.
Given these circumstances, and the symptoms described here, it is reasonable that a patient presenting an unidentified cutaneous lesion request of a physician that mucus swabbed from their nasal membranes be cultured on an agar plate and examined under a microscope.
In the face of an emerging threat, some people may effectively normalize the risk and find comfort by exploring the relatively low level of the threat compared to other risks. Others can find comfort in seeking scientific confirmation that they were not infected in a biological attack.
> If you are worried still, get the Cipro, take it for 10 days.
Bactericidal fluoroquinolones are not prescribed as a treatment for worry. If accurate information does not help to resolve worry, any of several anti-anxiety agents might be helpful. In treatment of cutaneous anthrax infection, a 60-day regimen of 500 mg ciprofloxacin bid has proven extremely effective. For pulmonary anthrax infections, intravenous ciprofloxacin has proven effective in some cases.
In late October, an estimated 10,000 U.S. residents were prescribed a 10-day regimen of ciprofloxacin as a prophylaxis while they awaited results of cultured nasal swabs. Prophylaxis is indicated in cases where a person is known to have been in an area where anthrax spores were identified. Preliminary anthrax tests of suspected substances can return results in a matter of hours and more precise tests can return results within 24 hours. Prophylaxis is not indicated in cases where a threatening communication has not led to a suspected substance, or where a suspected substance has not been identified as anthrax.
Medical testing for anthrax can be indicated even when no known source of infection is identified. Several of the 13 known cases of anthrax infection were identified through medical testing before any environmental tests identified a risk.
Unlike antimicrobial prophylaxis, mucus cultures do not involve risks to the patient, and present only nominal risks to the health system. The ready supply of agar plates is sufficient to immediately begin tests of a significant portion of the U.S. population, if such tests were indicated. Contraindications of widespread mucus culturing include a possible overload of testing laboratories, which could distract from other testing schedules. Conversely, when there is an emerging threat of biological warfare, a demand for increased testing capacity at medical laboratories can help promote surge capacity, which is sorely lacking in laboratories, pharmacies, hospitals and medical product manufacturing facilities.
When symptoms present that are suspected by a patient as possibly being anthrax infection, testing can contribute to the mental well-being of the patient. In cases where there are no presenting symptoms and no credible evidence of possible anthrax exposure, counseling and perhaps anti-anxiety medication are probably better approaches.
> Anthrax, in its aerosolized form, especially the high-grade strain in Daschel's office, will kill you in 3-4 days w/o treatment
Recent evidence suggests that contact with small diameter anthrax spores, possibly coated with bentonite to make them more buoyant, can cause cutaneous or pulminary infections or can cause no infection at all. The cutaneous lesion described here has been treated with antimicrobial agents for several days, which would likely reduce morbidity or delay mortality if the cause were anthrax. Whether it resulted from anthrax or another unknown pathogen, a change in treatment regime might be appropriate if treatments so far have not produced satisfactory results.
> waiting for the mud-slingers
Please see response at Psycho-Babble Administration.
http://www.dr-bob.org/babble/admin/20010718/msgs/2232.html
Posted by paxvox on October 27, 2001, at 16:08:42
In reply to Re: Could it be Anthrax? » paxvox, posted by Mitchell on October 27, 2001, at 1:43:00
Mitchell,
I have no idea of your education level or profession, but that was an EXCELLENT retort of my posting. Thank you for expounding upon my off the cuff projections. My main point,however, was to try and put this thing into perspective. What DO you do BTW?
PAX
standing aback
Posted by Mitchell on October 29, 2001, at 14:37:47
In reply to Re: Could it be Anthrax? » Mitchell, posted by paxvox on October 27, 2001, at 16:08:42
> Mitchell,
>
> ... that was an EXCELLENT retort of my posting.Ahw, shucks... ;-]
> > >What DO you do BTW?
I try to help. Obviously, I don't work for the Centers for Disease Control - their information should be considered more reliable. An excerpt of a 10/26 CDC statement is posted below. The addition of doxycycline as a first line antimicrobial is reportedly a new addition to their protocol. It's said to cost less and to be more readily available than ciprofloxacin.
The CDC advice most relevant to this discussion is that: "A high index of clinical suspicion and rapid administration of effective antimicrobial therapy is essential for prompt diagnosis and effective treatment of anthrax."
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5042a1.htm
Centers for Disease Control
Morbidity and Mortality Weekly Report
October 26, 2001 / 50(42);909-919
Update: Investigation of Bioterrorism-Related Anthrax and Interim Guidelines for Exposure Management and Antimicrobial Therapy, October 2001(excerpt)
Editorial Note:
Bioterrorism attacks using B. anthracis spores sent through the mail have resulted in 15 anthrax cases and three deaths. The initial anthrax cases occurred among persons with known or suspected contact with opened letters contaminated with B. anthracis spores. Later, investigations identified four confirmed cases and one suspected case among postal workers who had no known contact with contaminated opened letters. This suggests that sealed envelopes contaminated with B. anthracis passing through the postal system may be the source of exposure. The number of contaminated envelopes passing through the postal system is not known. In addition, automated sorting could damage envelopes and release spores into postal environments; other circumstances that could contribute to the contamination of postal facility environments may be identified.Because these cases are the result of intentional exposures, FBI and other law enforcement authorities are investigating these events as criminal acts and are working to identify and eliminate the source of these exposures. Until that occurs, the possibility of further exposure to B. anthracis and subsequent clinical illness exists. Clinicians and laboratorians should be vigilant for symptoms or laboratory findings that indicate B. anthracis infection, particularly among mail handlers. Information to guide health-care providers and laboratorians is available at < http://www.bt.cdc.gov >.
Managing Threats
Letters containing B. anthracis spores have been sent to persons in NYC and DC. Prompt identification of a threat and institution of appropriate measures may prevent inhalational anthrax. To prevent exposure to B. anthracis and subsequent infection, suspicious letters or packages should be recognized and appropriate protective steps taken.Characteristics of suspicious packages and letters include inappropriate or unusual labeling, strange return address or no return address, postmarks from a city or state different from the return address, excessive packaging material, and others. If a package appears suspicious, it should not be opened. The package should be handled as little as possible. The room should be vacated and secured promptly and appropriate security or law enforcement agencies promptly notified (Box 1).
Managing Exposures
Identification of a patient with anthrax or a confirmed exposure to B. anthracis should prompt an epidemiologic investigation. The highest priority is to identify at-risk persons and initiate appropriate interventions to protect them. The exposure circumstances are the most important factors that direct decisions about prophylaxis. Persons with an exposure or contact with an item or environment known, or suspected to be contaminated with B. anthracis---regardless of laboratory tests results---should be offered antimicrobial prophylaxis. Exposure or contact, not laboratory test results, is the basis for initiating such treatment. Culture of nasal swabs is used to detect anthrax spores. Nasal swabs can occasionally document exposure, but cannot rule out exposure to B. anthracis. As an adjunct to epidemiologic evaluations, nasal swabs may provide clues to help assess the exposure circumstances. In addition, rapid evaluation of contaminated powder, including particle size and characteristics, may prove useful in assessing the risk for inhalational anthrax.CDC is working with U.S. Postal Service employees and managers on several strategies to address the risk for anthrax among workers involved in mail handling. These strategies include personal protective equipment for workers handling mail and engineering controls in mail facilities. Clinicians and laboratorians should be vigilant for symptoms or laboratory findings that indicate possible anthrax infection, particularly among workers involved in mail sorting and distribution. Information to guide health-care providers and laboratories is available at < http://www.bt.cdc.gov > (1).
Antimicrobial Treatment
A high index of clinical suspicion and rapid administration of effective antimicrobial therapy is essential for prompt diagnosis and effective treatment of anthrax. Limited clinical experience is available and no controlled trials in humans have been performed to validate current treatment recommendations for inhalational anthrax. Based on studies in nonhuman primates and other animal and in vitro data, ciprofloxacin or doxycycline should be used for initial intravenous therapy until antimicrobial susceptibility results are known (Table 1). Because of the mortality associated with inhalational anthrax, two or more antimicrobial agents predicted to be effective are recommended; however, controlled studies to support a multiple drug approach are not available. Other agents with in vitro activity suggested for use in conjunction with ciprofloxacin or doxycycline include rifampin, vancomycin, imipenem, chloramphenicol, penicillin and ampicillin, clindamycin, and clarithromycin; but other than for penicillin, limited or no data exist regarding the use of these agents in the treatment of inhalational B. anthracis infection. Cephalosorins and trimethoprim-sulfamethoxazole should not be used for therapy. Regimens being used to treat patients described in this report include ciprofloxacin, rifampin, and vancomycin; and ciprofloxacin, rifampin, and clindamycin.Penicillin is labelled for use to treat inhalational anthrax. However, preliminary data indicate the presence of constitutive and inducible beta-lactamases in the B. anthracis isolates from Florida, NYC, and DC. Thus, treatment of systemic B. anthracis infection using a penicillin alone (i.e., penicillin G and ampicillin) is not recommended. The B. anthracis genome sequence shows that this organism encodes two beta-lactamases: a penicillinase and a cephalosporinase. Data in the literature also show that some beta-lactamase negative B. anthracis strains for which the penicillin MICs are 0.06 µg/mL increase to 64 µg/mL and become beta-lactamase positive when exposed to semisynthetic penicillins (4). The frequency of this induction event is unknown. Although amoxicillin/clavulanic acid is more active than amoxicillin alone against beta-lactamase, producing strains in vitro, the combination may not be clinically effective for inhalational anthrax where large numbers of organisms are likely to be present.
Toxin-mediated morbidity is a major complication of systemic anthrax. Corticosteroids have been suggested as adjunct therapy for inhalational anthrax associated with extensive edema, respiratory compromise, and meningitis (5).
For cutaneous anthrax, ciprofloxacin and doxycycline also are first-line therapy (Table 2). As for inhalational disease, intravenous therapy with a multidrug regimen is recommended for cutaneous anthrax with signs of systemic involvement, for extensive edema, or for lesions on the head and neck (Table 2). In cutaneous anthrax, antimicrobial treatment may render lesions culture negative in 24 hours, although progression to eschar formation still occurs (5). Some experts recommend that corticosteroids be considered for extensive edema or swelling of the head and neck region associated with cutaneous anthrax. Cutaneous anthrax is typically treated for 7--10 days; however, in this bioterrorism attack, the risk for simultaneous aerosol exposure appears to be high. Although infection may produce an effective immune response, a potential for reactivation of latent infection may exist. Therefore, persons with cutaneous anthrax associated with this attack should be treated for 60 days.
Prophylaxis for inhalational anthrax exposure has been addressed in a previous report (1) and indicates the use of either ciprofloxacin or doxycycline as first line agents. High-dose penicillin (e.g., amoxicillin or penicillin VK) may be an option for antimicrobial prophylaxis when ciprofloxacin or doxycycline are contraindicated. The likelihood of beta-lactamase induction events that would increase the penicillin MIC is lower when only small numbers of vegetative cells are present, such as during antimicrobial prophylaxis.
All medications may have undesirable side effects and allergic reactions may result from any medication. Clinicians prescribing these medications should be aware of their side effects and consult an infectious disease specialist as needed. Patients should be urged to inform their health-care provider of any adverse event.
This is the first bioterrorism-related anthrax attack in the United States, and the public health ramifications of this attack continue to evolve. Additional updates and recommendations will be published in MMWR.
This is the end of the thread.
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