VISCERAL ANTHRAX IMPORTED FROM AFRICA

Widespread vaccination has largely eliminated anthrax in Europe (the l ast case was reported in France in 1972) but the disease remains endem ic in many developing countries. The usual cutaneous presentation (mal ignant pustules) is much more familiar than the various visceral manif estations including digestive tract, pulmonary or meningeal signs. We report a case of a 33-year-old immigrant living in France who was hosp italized for asthenia, dyspnoea, mucopurulant expectoration and modera te diarrhoea 3 days after a 3-month stay in Senegal and Gambia. The te mperature was 39 degrees C at admission and blood pressure 110/70 mmHg . Crepitants were heard at the base of the right lung and the rest of the physical examination was normal. Blood was drawn for culture. Labo ratory tests and the chest X-ray led to the diagnosis of pneumopathy a nd a treatment of amoxicillin and clavulanic acid was given with oxyge notherapy. The patient's temperature returned to normal but over the n ext 48 hours the dyspnoea worsened together with the black diarrhoea. The abdomen was painful. There were no skin lesions. The chest X-ray r evealed an extension of the bilateral pulmonary images and bilateral p leural effusion. Laboratory tests revealed thrombopenia (platelet coun t 38,000/mm(3)) hyperleukocytosis (WBC 48,000/mm(3)) and haemolysis (H b 4 g/l). The diagnosis was made on the basis of the initial blood cul tures which were positive for Bacillus anthracis. All other samples we re negative, including HIV serology. Despite adapted antibiotic therap y (penicillin G, 8MU/day, was initiated on day 2), multiple organ fail ure occurred with septic shock and pulmonary oedema. The patient died in the intensive care unit on day 7. Fatal outcome due to anthrax is d escribed in 25% of the visceral forms but reaches 100% in cases of sep ticaemia. The haemolysis observed in this case is not mentioned in the classical descriptions of anthrax. When treating septic syndromes in patients who have returned from endemic zones, clinicians should enter tain the diagnosis of anthrax since the risk of fatal outcome is incre ased greatly in case of delayed diagnosis.