Correspondence
Cutaneous Anthrax Infection
N Engl J Med 2002; 346:945-946March 21, 2002
- Article
To the Editor:
Like many other clinicians, we were disheartened by the report of the diagnosis of cutaneous anthrax in a seven-month-old child (Nov. 29 issue).1 However, what we found most distressing about this and other cases was that the initial diagnosis was envenomation by the brown recluse spider, Loxosceles reclusa. Although envenomation by this spider produces a necrotic lesion that may be mistaken for cutaneous anthrax, there are some critical differences that can help to guide future evaluations.
Loxosceles spiders prefer warm temperatures, and they are not native to the northern half of the United States.2 In fact, no spider causing necrotic lesions is known to live in New York City. Furthermore, as the spider's name implies, these spiders are most commonly found hidden in woodpiles or barns — areas that are not typically visited by small children, as evidenced by the fact that few case series have included small children.3,4
Examination of the patient with a loxosceles bite generally reveals a painful blister, which may develop a dark purple coloration, with subsequent central necrosis of the lesion.3 Unlike such bites, the lesions associated with cutaneous anthrax are often painless. The substantial edema and regional adenopathy that are characteristic of cutaneous anthrax are generally absent in patients with loxosceles envenomation.5 Thus, despite some superficial similarity, a painless, edematous, necrotic lesion with local adenopathy in a person in the northeastern United States, especially in the colder months, is not likely to represent necrotic arachnidism.
5 ReferencesLewis S. Nelson, M.D.
New York City Poison Control Center, New York, NY 10016
lnelson@pol.net Robert Hanner, Ph.D.
American Museum of Natural History, New York, NY 10024Robert S. Hoffman, M.D.
New York City Poison Control Center, New York, NY 100161
Roche KJ ,Chang MW ,Lazarus H . Cutaneous anthrax infection. N Engl J Med 2001;345:1611-1611
Full Text | Web of Science | Medline2
Necrotic arachnidism -- Pacific Northwest, 1988-1996. MMWR Morb Mortal Wkly Rep 1996;45:433-436
Medline3
Wright SW ,Wrenn KD ,Murray L ,Seger D . Clinical presentation and outcome of brown recluse spider bite. Ann Emerg Med 1997;30:28-32
CrossRef | Web of Science | Medline4
Ingber A ,Trattner A ,Cleper R ,Sandbank M . Morbidity of brown recluse spider bites: clinical picture, treatment and prognosis. Acta Derm Venereol 1991;71:337-340
Web of Science | Medline5
Dixon TC ,Meselson M ,Guillemin J ,Hanna PC . Anthrax. N Engl J Med 1999;341:815-826
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: The purpose of this Image in Clinical Medicine was to present an example of early cutaneous anthrax, since most reports show older, necrotic lesions. Because of space limitations, we did not discuss the differential diagnosis or other important issues involved in this complicated case.
We agree that the painless nature of the lesion was not typical of the bite of a brown recluse spider and that necrotic arachnidism in an infant in Manhattan is very unlikely. However, we could not rule out this possibility. Although loxosceles spiders are most highly concentrated in the south central United States, loxosceles species have been identified in virtually every state in the continental United States,1 and according to one spider expert, a “cousin” of the brown recluse spider, L. refuscens, had recently been sighted in the New York area. The family's car had recently been in regions inhabited by loxosceles species, and we postulated that a spider might have hidden in the infant's stroller or in the family's belongings. Although loxosceles bites are most common in the summer, a second peak can occur when victims unpack boxes and resume wearing stored winter clothing in which the spider may be hiding.2 Furthermore, life-threatening hemolysis, thrombocytopenia, disseminated intravascular coagulation, hyponatremia, and acute renal failure developed in this infant, and all of these complications have been well described in patients with loxosceles envenomation.1,2 A putative brown recluse spider bite1,2 was the initial working diagnosis; since there is no specific antidote for such bites, the patient received antibiotics, corticosteroids, and supportive care, which was the appropriate therapy, even in retrospect.
At the time, anthrax in a seven-month-old child in Manhattan seemed nearly impossible. In fact, between 1984 and 2000, only five cases of cutaneous anthrax were reported in this country, and none of these occurred in children.3,4 During this child's hospitalization, the first case of cutaneous anthrax in New York City was reported. The correct diagnosis in the child was then rapidly confirmed. The constellation of systemic complications is highly unusual in a patient of any age with cutaneous anthrax, and such complications have never been reported in a child, even in countries where anthrax is endemic.5 Fortunately, the infection responded well to therapy, and the child recovered fully.
We are certainly wiser now than we were before September 11, 2001. A full case report of this infant's illness has been published, including serial photographs of the evolving lesion.5 The early recognition of anthrax is crucial in patients of all ages.
5 ReferencesMary Wu Chang, M.D.
Kevin Roche, M.D.
Herbert Lazarus, M.D.
New York University School of Medicine, New York, NY 10016
changm02@med.nyu. edu 1
Wilson DC ,King LE Jr . Spiders and spider bites. Dermatol Clin 1990;8:277-286
Web of Science | Medline2
Sams HH ,Dunnick CA ,Smith ML ,King LE Jr . Necrotic arachnidism. J Am Acad Dermatol 2001;44:561-573
CrossRef | Web of Science | Medline3
Summary of notifiable diseases, United States, 1999. MMWR Morb Mortal Wkly Rep 1999;48:82-89
4
Summary of notifiable diseases, United States, 1945-1994. MMWR Morb Mortal Wkly Rep 1994;43:70-78
5
Freedman A ,Afonja O ,Chang MW , et al. Cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant. JAMA 2002;287:869-874
CrossRef | Web of Science | Medline
