ANTHRAX MENINGITIS.
REPORT OF A CASE OF INTERNAL ANTHRAX WITH RECOVERY*
ROBERT H. SHANAHAN, M.D., JOSEPH R. GRIFFIN, M.D., AND
ALFRED P. VON AUERSPERG, M.D.
From the Department of Medicine, St. John's Riverside Hospital, Yonkers, New York
Anthrax meningitis has always been considered malignant and we have been
unable to find any reports in the literature of its successful treatment. Favorable results, however, have been reported of the use of penicillin in experimental animal anthrax 1 and there are also recent reports of the cure of cutaneous
anthrax in man by the use of penicillin.3
A resume of 66 cases of anthrax at the Alexander Smith and Sons Carpet
Company2 revealed four deaths. One case was complicated by diabetes mellitus,
and the other three patients died of anthrax meningitis.
REPORT OF CASE
A white man, aged 57, was employed as a wool picker at the carpet shop for
two weeks. He presented himself at the infirmary on September 23, 1946,
showing a vesicular lesion on the upper lip, 0.5 cm. in diameter, surrounded
by edema, which had been present for twenty-four hours. Anthrax was suspected, the patient was hospitalized at once, and a culture and smear were made
from the lesion. Numerous gram-positive bacilli having the morphology of
B. anthracis were seen and a culture and inoculation of a mouse confirmed the
diagnosis of anthrax infection.
First day of hospitalization (September 24). The initial treatment consisted
of 100,000 units of penicillin followed by 100 cc. of antianthrax serum (Lederle
Laboratories, Inc., New York, N. Y.) both of which were given intramuscularly.
Second day. The temperature rose to 102 F. and the right submaxillary lymph
glands became enlarged. Pain and bulging behind the right eye indicated
pressure, suggesting cavernous sinus thrombosis. During the night, it was
noted that the patient developed some twitching in the arms and face; he complained of pain in the back of the neck. Cultures of blood and pus were positive
for B. anthracis.
A spinal tap was performed and the fluid appeared clear, the cell count was
0, the sugar, chloride and globulin were all normal. A culture of the cerebrospinal fluid was taken and a guinea pig inoculation was performed. Despite
the normal microscopic and chemical findings, meningeal involvement was suspected and 30,000 units of penicillin were injected intrathecally. The patient
was given 4 gm. of sulfadiazine initially, followed by 1 gm. every four hours.
Culture was made and B. anthracis was isolated from the otherwise negative
spinal fluid.
* Received for publication, June 23, 1947.
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Eight hours later, the temperature rose to 103.8 F. and the patient developed
rigidity of the neck, a Kernig's sign, and a Babinski's sign. A second spinal
tap at this time revealed very cloudy fluid, a cell count of 3500 cells per cu.
mm., 4 plus globulin, negative sugar, 1200 mg. protein, and 760 mg. chloride.
FIG. 1. Photograph of patient taken October 1, 1946, on eighth day of hospitalization.
Twenty thousand units of penicillin were again injected intrathecally, and cultures were again made and reported as positive twenty-four hours later.
Third day. During the night, the temperature began to fall; by 8:00 A.M.
it was 102 F. Another spinal tap was performed. The cell count was 328
per cu. mm., sugar 0, globulin 0. Twenty thousand units of penicillin were
injected intrathecally and a spinal tap at 7:00 P.M. revealed 42 cells per cu.
ANTHRAX MENINGITIS
721
mm. Twenty thousand units of penicillin were again injected intrathecally
and by midnight the temperature was 100 F. Culture of this fluid was positive
for B. anthracis.
Fourth day. A spinal fluid examination at 8:00 A.M. revealed a cell count
of 22 cells per cu. mm., normal reduction of sugar and negative globulin. Another 20,000 units of penicillin were administered intrathecally. Culture of
the spinal fluid was negative.
Fifth to eighth days. The patient's temperature remained within normal
limits; his meningeal irritation slowly disappeared and the lesion took on the
appearance of a black, gangrenous, crusted area measuring 1.5 cm. in diameter.
The edema surrounding the area disappeared and the enlarged glands in the neck
also subsided.
TABLE 1
SUMMARY OF M E D I C A T I O N G I V E N TO P A T I E N T I N T R E A T M E N T OF ANTHRAX I N F E C T I O N OF
L I P AND M E N I N G E S
1. Total of 500 cc. of antianthrax serum i n t r a m u s c u l a r l y : 100 cc. given September 23
1946, and 50 cc. given every eight hours thereafter for 8 doses, up t o September 27
1946.
2. Total of 110,000 units of penicillin intrathecally: 30,000 units given initially followed b y
20,000 units every twelve hours for 5 doses.
3. Total of 4,400,000 units of penicillin intramuscularly: 100,000 units given every three
hours from September 23 to September 27, 1946, and 50,000 units given every three
hours from September 27 t o September 30, 1946.
4. Continuous 1:4000 wet penicillin dressing to lesion.
5. Total of 28 gm. sulfadiazine: Pour gm. given initially followed by 1 gm. every four
hours from September 24 t o September 28, 1946.
Ninth day. The patient developed the following symptoms of serum sickness:
pruritus, urticaria, back pain and a mild rise in temperature. All of these
symptoms disappeared within the next two days.
Fifteenth day. The hard crusted lesion dropped off the upper lip leaving no
visible scar.
Twenty-eighth day. The patient was able to report back to work.
SUMMARY AND CONCLUSIONS
From a review of the literature and from the cases of infection at a carpet
shop, one is impressed with the following facts:
1. While anthrax infection is rare, its occurrence among wool workers is
sufficiently frequent that one should always be suspicious of cutaneous lesions
in such workers.
2. The incidence of meningeal involvement in anthrax infection is about 5
per cent. In the treatment of anthrax one should be constantly on the alert
for evidence of meningeal involvement.
3. Treatment for meningeal anthrax infection should be instituted immediately
upon clinical evidence of meningeal irritation. In the case reported here, the
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appearance of the first spinal fluid taken was entirely negative but mouse inoculation was positive and culture was reported positive twenty-four hours after
the treatment was started. There was excellent response to the medication
which consisted of penicillin intramuscularly and intrathecally, and locally to
a skin lesion, antianthrax serum intramuscularly and sulfadiazine by mouth.
4. Owing to the rapid development of meningeal involvement in anthrax
infection, it appears that antianthrax serum alone is ineffective, but in this
case the penicillin may have inhibited the growth of the organisms until the
antiserum had sufficient time to act. Inasmuch as previous cases of anthrax
meningitis treated without penicillin all terminated fatally, one may speculate
on a synergistic action between the antianthrax serum and penicillin in this case.
REFERENCES
1. M C C U L L O U G H , K . , AND VON ATJERSPERG, A.: Effect of penicillin and antianthrax serum
in experimental anthrax. Am. J . Clin. P a t h . , 17: 151-154, 1947.
2. S M I T H , A L E X A N D E R AND SONS C A R P E T COMPANY, Y O N K E R S , N E W Y O R K : Communication
from t h e medical d e p a r t m e n t t o t h e authors, 1946.
3. STOTT, H . : T r e a t m e n t of human cutaneous anthrax with penicillin.
120, 1945.
Brit. M . J., 2 :