Learning Anthrax, Case by Case

When Dr. Carlos Omenaca first saw Ernesto Blanco lying in a hospital bed, he instantly knew that the patient was gravely ill.

“He was breathing very fast--he required high concentrations of oxygen just to keep him going,” says Omenaca, an infectious disease doctor in Miami. “He was saying, ‘Oh, I’m fine,’ and, ‘No, I have no trouble breathing,’ and he was breathing 40 [times] a minute when a normal person breathes between 12 and 14.”

Blanco already had been at Miami’s Cedars Medical Center for a couple of days. Doctors thought the 73-year-old man had a bad case of pneumonia.

But then, Omenaca heard the news that Robert Stevens, a photo editor at American Media Inc., had been diagnosed with inhalation anthrax. His patient, he learned, worked in the same building in nearby Boca Raton.

For Omenaca, that news opened a three-week scramble to learn about--and try to conquer--a disease that he and most other infectious disease specialists had never encountered.

In the weeks to come, he would be joined by doctors in Virginia, Maryland and New Jersey.

Together, they have learned much: They now know what anthrax looks like. They know what antibiotics are most effective against it. Most important, they know that with a bit of luck and considerable effort, it can be beaten.

Although Stevens and two other inhalation anthrax patients have died, Blanco has gone home. Three patients in the Washington area with confirmed cases of the illness are stable, as are at least two in New Jersey with inhalation cases that are suspected but not yet confirmed.

“We have at least four people who are stable and improved, in fact, one person who’s been discharged from the hospital after inhalation anthrax,” Dr. Julie Gerberding, senior epidemiologist at the national Centers for Disease Control and Prevention, said at a Thursday news conference.

Doctors “are doing better than we would generally expect,” Gerberding said.

Inhalation anthrax is still extremely dangerous. But the general belief among medical experts before Oct. 1 that it was almost invariably fatal was based on scant data from decades ago. Today’s superior medical care, experts now believe, can make a significant difference to a patient’s chances.

“The fact that they are stable for this many days after being diagnosed is a good sign--though I don’t think we can say for sure what the final outcome will be,” said Dr. Saadia Griffith-Howard, infectious disease specialist with the Kaiser Permanente Health Plan of the Mid-Atlantic states, which is caring for two of the three confirmed cases.

Care, Antibiotics Are Much Improved

A variety of factors could account for this small silver lining: better antibiotics, better critical care and less time before diagnosis than in historical cases.

The biggest recorded human experience with inhalation anthrax comes from Soviet-era Russia, where a leak of spores from a biological weapons facility in 1979 killed at least 64 people in the industrial city of Sverdlovsk.

The incident was covered up for years; most of the medical papers were destroyed. To this day, it’s unclear how many people died, how sick they were before seeking help and what kind of medical care they received.

Only 11 people are on record as having survived the infection--most died within a day of being hospitalized--but Soviet-era medical care was not great even under the best conditions.

Moreover, survival numbers could be biased toward a more gloomy prognosis because less-seriously ill people may have survived but never made it into available records.

The other human outbreak that is used to calculate mortality occurred in the U.S. in 1957 at a New Hampshire textile mill. Five workers contracted the disease from goat hair contaminated with anthrax spores.

Four died even though they were treated with intravenous doses of antibiotics, though perhaps in lower doses than those being used today, recalled Dr. Philip Brachman.

Brachman, a professor at the Rollins School of Public Health at Emory University in Atlanta, investigated the outbreak while head of epidemiology at the CDC.

But the difference between medicine in the 1950s and now is like night and day, said Dr. Paul Krogstad, a UCLA infectious disease specialist.

“The 1957 report is quaint--it even speaks about physicians performing house calls,” Krogstad said. In so many ways, he said, “we’re almost talking about a different type of medicine.”

These days, intensive-care units are vastly better at managing serious illnesses. Mechanical ventilators assist breathing, and drugs manage complications such as hemorrhage and plummeting blood pressure that infections like anthrax can cause.

There are also more potent, and varied, antibiotics--and a wealth of experience in using them to manage other bacterial infections.

New guidelines released Friday by the CDC recommend using several antibiotics to treat confirmed inhalation anthrax cases--ciprofloxacin or doxycycline and one or two others from a list of seven.

Moreover, it may be that even in years past, anthrax was not as uniformly deadly as people believed. “Maybe we’ve not seen enough anthrax to recognize that there’s a milder form of inhalational anthrax,” Brachman said.

The speed and quality of care a patient receives can make a difference. Two postal workers from the Washington area died from anthrax this week. At least one of them initially went to a local hospital, where doctors did not ask him where he worked and diagnosed his illness as the flu. By the time he returned to the hospital the next day, he was near death.

Inhalation anthrax is hard to diagnose because the early symptoms look so much like flu or other viral infections.

Blanco’s first symptoms, for example, included a cough, malaise, body pains and lack of energy. By the time he sought help, he had a high fever and labored breathing--and he grew sicker rapidly.

At one point he fell into shock--his blood pressure fell precipitously and his heart started beating arrhythmically, all effects of the bacteria teeming in his bloodstream and the toxins it was making. Drugs pulled him back.

Fluid in great quantities accumulated around Blanco’s lungs. The doctors had to use needles to draw it out so he could breathe.

Two weeks of intensive care went by before he improved, and “I thought, ‘Well, I think he’s going to make it,’ ” Omenaca said.

Doctors treating the two patients at Inova Fairfax Hospital outside Washington faced similar challenges, which they have fought by using a combination of three drugs: ciprofloxacin as well as rifampin and clindamycin.

Different antibiotics have different characteristics, and the idea is to assault the bacterium on several fronts so it doesn’t survive long enough to produce lethal levels of toxin.

Medical Learning Curve Is Steep

Ciprofloxacin is potent, but rifampin is better at getting into parts of the body that ciprofloxacin might not reach, including the brain.

And clindamycin interferes with the ability of bacteria to make proteins and thus may stop anthrax toxins from building up. Studies in animals and some people show it helps avoid toxin buildup in infections with the microbes colloquially known as “flesh-eating bacteria.”

Even so, for those involved in tending, screening for or tracking the few patients who have the infection, the learning curve is steep.

“We’d read about it, we’d heard about it, but we’d never, ever seen it. We’ve never faced this type of a situation,” said Griffith-Howard.

“We are definitely learning a lot.”

Doctors all over the country are similarly beefing up--hitting the books, surfing the CDC’s anthrax Web pages--in preparation for what they hope they will never have to encounter.

The thirst for knowledge is apparent at the current meeting of the Infectious Diseases Society of America in San Francisco--where anthrax has for now eclipsed HIV and AIDS as the main point of discussion.

Specialists have crowded into oversubscribed talks on bioterrorism in all its shapes and guises, and extra sessions on these topics featuring world experts have been hastily added in the light of current events.

“We’re the people that people are looking to” for answers, said Krogstad. “There’s a great deal of interest in making sure we are up to date.”

But with any luck, the detailed statistics on who survives inhalation anthrax will still be soft when the current spate of infections is over.

“You can’t tell much from a small sample,” Omenaca said.

Nobody wants a large one.