Snapshot A 45-year-old farmer presents to the clinic with a one week history of black sores on his right forearm. He recalls grazing his forearms while working on his grain harvester a couple of weeks ago. Initial lesions were pimples which became pustular and turned necrotic with black sores. There is no history of IV drug abuse. His temperature is 100.4°F (38°C), blood pressure is 140/80mmHg, pulse is 90/min, respirations are 16/min. Physical exam reveals an ill-looking man with a grossly edematous right forearm on which are several painless necrotic ulcers with black depressed eschar. There is right axillary and epitrochlear lymphadenopathy. Chest is clear to auscultaton. Abdomen is soft and non-tender. Samples were sent out for blood culture. Chest radiograph taken was normal. A swab of the eschar was taken for Gram stain, culture, and PCR. The local health authorities were notified. Introduction Classification bacteria gram positive bacilli spore-forming Bacillus Bacillus anthracis Transmitted via animal wool, hides, hair, and bone biological weapon IV drug use and notably heroin Presentation Cutaneous pruritic papule enlarges to form ulcer satellite lesions edematous halo round, regular, raised edge ulcer becomes black eschar regional lymphadenopathy is typical lesion develops 1-7 days following exposure Inhalational causes hemorrhagic mediastinitis fever dyspnea hypoxia hypotension 1-3 days following exposure GI caused by ingestion of contaminated meat dysphagia nausea/vomiting dysentery abdominal pain Evaluation CXR widened mediastinum with inhalational form Culture is high yield if prior to antibiotics ulcer/eschar pleural fluid blood If pre-treated with antibiotics serological testing punch biopsy for histopathology Differential Inhalational community-acquired pneumonia influenza Cutaneous bubonic plague lymphocutaneous tularaemia primary syphillis Gastrointestinal etiology of infectious diarrhea Treatment Ciprofloxacin or doxycycline for cutaneous anthrax then prophylax against inhalational disease by continuing for 60 days Prognosis, Prevention and Complications Prognosis good if treated early with antibiotics worse if inhalational or bacteremic Prevention post-exposure prophylaxis ciprofloxacin or doxycycline vaccination subcutaneous anthrax vaccine adsorbed (AVA) three doses two weeks apart monoclonal antibodies when alternative therapies are not appropriate raxibacumab or obiltoxaximab Complications bacteremia leading to sepsis meningitis