Correspondence

Cutaneous Bacillus anthracis Infection

N Engl J Med 2001; 345:1646-1647November 29, 2001

Article

To the Editor:

We report the case of an otherwise healthy 34-year-old man, employed in the mailroom of a New York City daily newspaper, who presented with a rapidly growing nodule over the flexor surface of his left forearm (Figure 1Figure 1 Bacillus anthracis Lesion on the Forearm of the Patient.). He stated that the lesion had begun as a “pimple” six days earlier. Initially, the lesion was pruritic and erythematous. Within 24 hours, the pruritis resolved and the nodule developed a central black eschar. The patient said that he had no fever, chills, or respiratory or gastrointestinal symptoms. Because of both the characteristics of the lesion and the diagnosis of cutaneous anthrax in one of the patient's coworkers, a referring physician had prescribed ciprofloxacin (500 mg two times daily), which the patient had taken for the three days preceding his presentation.

On physical examination, there was a 1.5-cm nontender, erythematous nodule with a central, 0.4-cm black eschar on the left forearm. There were three intact vesicles, 0.1 to 0.2 cm in diameter, on the surface of the nodule. Surrounding the nodule was an erythematous, indurated plaque, 6.5 cm in diameter. Mild swelling of the forearm was evident. There was no lymphangitis or lymphadenopathy. The physical examination was otherwise unremarkable.

Hematoxylin–eosin staining of lesional tissue revealed marked superficial papillary edema, diffuse interstitial inflammation with focal blood-vessel congestion, and acute vasculitis. A Gram's stain revealed gram-positive rods, and immunohistochemical analysis confirmed the presence of Bacillus anthracis.

The patient continued to take the same dose of ciprofloxacin. At a follow-up examination one week after presentation, the size of the lesion had diminished and the surrounding erythema had resolved. He remained free of constitutional symptoms.

T. Casey Gallagher, M.D.
Bellevue Hospital, New York, NY 10016
tcaseygallagher@yahoo.com

Bruce E. Strober, M.D., Ph.D.
New York University School of Medicine, New York, NY 10016