Intestinal anthrax in a 4-year-old child Professor M.H. Soltanzadeh MD Professor of Pediatrics, ID , Shahid Beheshti University of Medical Science , Tehran ,IRAN Siadati A MD1  ,Shirvani F MD2  , Sardari M MD3 , Rashed F MD4 , Soltanzadeh M.H. MD , ID5 , ,   Shafagi B MD6 , Gharooni M  MS7

1- Ahmad  Siadati MD , Professor of Pediatric Infectious Diseases , Markaztebi Hospital , Dr Mohamad garib St. , Tehran University of Medical Sciences and Health Services , (Tehran, Iran) 2 - Fariba Shirvani MD, Assistant Professor of Pediatrics , Imam Hossein Hospital, Shaheed Madani Street , Shaheed Beheshti University of Medical Sciences and Health Services,(Tehran, Iran)        Email: shirvanif@yahoo.com 3 – Mehdi Sardari MD, General Practitioner , Imam Hossein Hospital, Shaheed Madani Street , Shaheed Beheshti University of Medical Sciences and Health Services ,(Tehran, Iran) 4 – Farinaz Rashedmarandi MD, Assistant professor of pathology, Director of department of microbiology, Reference laboratory of Iran, research center, Boali Hospital, Imam Hossein square, Damavand Street, (Tehran-Iran) 5 -Mohammed Hosein Soltanzadeh MD ,  ID,Professor of Pediatrics , Imam Hossein Hospital, Shaheed Madani Street , Shaheed Beheshti University of Medical Sciences and Health Services,(Tehran, Iran) 6–Behroz Shafagi MD , Assistant Professor of Pathology, Imam Hossein Hospital, Shaheed Madani Street , Shaheed Beheshti University of Medical Sciences and Health Services,(Tehran, Iran) 7–Manijeh Garooni MS, Microbiologist , Laboratory of Imam Hossein Hospital,   Shaheed Madani Street , Shaheed Beheshti University of Medical Sciences and Health Services ,(Tehran, Iran) Key words: anthrax, child Abbreviated title: intestinal anthrax ABSTRACT: Anthrax is the most fetal infectious disease that still, because of incorrect and prompt diagnosis results to death. Its intestinal form is the most severe and rarest one. This article is about a 4- year old boy with abdominal pain and vomiting and distention and bad general condition from a few days before admission and was operated with a probability of peritonitis. Right hemicolectomy because of ileocecal region invagination and perforation was done but  four hours later, the patient died with septic shock. This article tries to demonstrate the importance of epidemiological control of this disease that todays is on the world concern, besides awareness of necessary implications for prompt diagnosis  and treatment can save the patient life. INTRODUCTION: Anthrax is caused by a gram negative anaerobic bacillus which lives in soil. It affects animals such as cow, sheep, horse, goat and pig. Human transmission occurs by direct (with animal meat and blood ) and indirect ( with animal hair and wool) contact. Anthrax affects skin , lung , and GI tract and all these three forms can involve CNS . Skin form is the most common and GI form is the rarest (1). There are a few reports of intestinal anthrax in literature: an eleven year old girl with GI and CNS form from Poitzer (France)(2), a 2 year old Iranian child with GI form (3), a 20 year old woman with GI form (1970) (4). In addition to bioterrorism , world trade system and international products transport from andemic places is still an important threat . CASEREPORT: : a 4 year old boy was admitted at  August 11 , 2002 in Imam Hosein Hospital (TEHRAN,IRAN) , he had a history of a two days gradual abdominal pain and distention with constipation and one day vomiting and fever . There was no family history of a disease but a suspicious contact with a dead animal was detected. Axillary temperature was 38.5 c , systolic pressure 110 mmHg , RR 45/min and PR 125/min , he had an ill appearance , bowel sounds were hypoactive .  In rectal examiunation there was normal stool without obvious blood , kernig and brudzinsky signs were negative , blood specimen was sent to laboratory and Antibiotic therapy with Amikacin , Clindamycin and Ceftriaxone was started . Chest XRay was normal. Plain  abdominal X ray showed midposition of gut because of ascitis and edematous luminal boarders . Abdominal sonography showed liver nodularity and extensive ascitis , bowel loops expansion with fluid and gas but there was no organomegally. A specimen was aspirated from the ascitis which had a pussy appearance , gram strain preparation showed a lot of WBC and RBC with gram positive bacillus . (table 1 ) Table 1 – Lab.  Results from the patient with GI Anthrax in IMAM HOSEIN Hospital (Tehran – Iran ) Laboratory examination Results blood Hgb (gr/dl) 16.6 WBC (mm3) 41000 PMN %78 Biochemistry Urea (mg/dl) 72 Na (meq/lit) 120 K (meq/lit) 5 Ca  (meq/lit) 9.3 Creatinine 0.9 Ascitis WBC (mm3) 4200 PMN %85 RBC (mm3) 4700 U/A WBC (mm3) 1-2 S/E WBC (mm3) 25-30 RBC (mm3) 20-25

Blood and ascitis fluid was sent for smear and culture . After one hour of admission and in concern to progressive abdominal distention and rebound tendernerness and laboratory results , acute surgical abdomen and peritonitis secondary to bowel lumen perforation was suspected and elective laparatomy was done , after midabdominal incision  2-2.5 litre fluid poured out and ileocecal intussusception was detected and extensive necrosis and perforation was detected . a right hemicolectomy and small bowel resection was done . In pathologic examination, edema and necrosis and intestinal perforation and colonization of gram positive organisms on perforation site was seen .  There was 40 acute suppurative adenopathy in paracecal and ileal region (figure2,3 ).

After operation the patient admitted to ICU and ampicillin ,amikacin and metronidazole was started . By the way pulse rate reduction not responding to drug therapy and hypotension occurred and the patient died with septic shock. On blood and acsitis smear preparation there was a lot of gram positive bacillus with ellipsoidal central endospores . Specimens cultured on blood agar and after 18 hours of incubation colonies appeared with irregular boarders and 5 mm width , smear from colonies showed gram positive bacillus with smooth ellipsoid central boarders(figure4), on secondary culture on sheep agar there was no hemolysis , organism had no movement , it was lecithinase positive on egg yolk agar , no acid formation from salicin, nitrate positive, endole negative, gelatin hydrolysis after seven days was positive and it was sensitive to penicillin (10IU). These LAB examinations were done in REFERENCE laboratory (Tehran – Iran)

And diagnostic confirmation was done in RAZI institute of research .(Tehran – Iran)

DISSCUSSION:
Anthrax has a known cycle in nature including 1 – spores multiplication in soil 2- animal infection and 3 – human infection(1).

With PH increasing to more than 6 and supplementation with (animal waste) and after intermittent rainfall , spores become activated and multiply . important factor in epidemiology and disease control is viable spores persistance for a few decades .

Yearly report of this disease is200-2000 cases but there are cases that are not reported . Three forms of disease (skin more than 95% ) and GI and respiratory form exists . Because of animal control and vaccination , the disease is very rare in USA . Meanwhile it is endemic in Iran , Turkish , Pakistan and Sudan and after domestics infection , human disease and GI anthrax (by infected meat consumption) is possible.There are important factors for effective diagnosis and treatment , skin form is easily distinguishable by the black central scar but GI form based on bowel or pharyngeal involvement may have signs as bloody vomiting , melena or bloody diarrhea, bloody pussy ascitis , erythematous cervical lymphadenitis and edema and  disphagia(5). In nontreated cases there is sever toxicity , intestinal perforation , peritonitis or in our patient intussusception caused by ileal adenopathy . He had no history of bloody vomiting or stool but tense ascitis and abdominal distention was found. Because of nonspecific signs and rareness this disease cannot be placed in differential diagnosis (6). Direct ascitis and pleural fluid smear and blood culture is helpful. Titer rising 3 to 6 months after beginning of illness can be detected. GI Anthrax should be differentiated from duodenal ulcer , thyphoid and tularemia(5). Penicillin is used for systemic and skin form and in meningitis streptomycin and ciprofloxacine is added . Treatment period is 14 days but because of diagnosis delay it was not recommended for our patient . Mortality in GI form is more than 50% and more than 100% in respiratory form(5). Awareness of anthrax signs and symptoms , having clinical suspection and appropriate treatment by penicillin or in cases of hypersensitivity , erythromycin , ciprofloxacin or tetracycline increases treatment success. High risk people vaccination is recommended and prophylaxis by penicillin till 7 days after contact with bacillus is beneficial (5).

CONCLUSION:
Anthrax is endemic in Iran , therefore it should be suspected in cases of GI and respiratory tract bleeding or sever peritonitis and septicemia in people in contact with domestic animals and their products . because of high sensitivity of this organism to penicillin , it can be used with 400000IU/kg in 4 to 6 divided doses and in combination with other drugs .careful report of disease and identification of endemic sources and domestic animals ans their vaccination , use of detergents such as formaldeid (1) are done to disinfect the soil .

REFERENCES:

1–Koneman EW, Allen DS, Janda WM, Schreckenberger PC, Winn WC, Color Atlas and Textbook of Diagnostic Microbiology, 5^th edition, Philadelphia , Lippincott        

2 - Berthier M, Fauchere JL, Perrin J, Grignon B, Oriot D. fulminant meningitis due to bacillus nthracis in 11 year old girl during Ramadan, The Lancet 1996; 347:828

3-Alizad A, Ayoub EM, Makki N. Intestinal anthrax in a 2-year-old child, The Pediatric Infectious Disease Journal 1995; 14(6): 394-5

4 - Nalin DR, Sultana B. Survival of a patient with intestinal anthrax, Am J Med 1997; 62:130-2

5 - Edwards MS. Anthrax In: Feigin RF, Cherry JO eds. Textbook of pediatric infectious disease, 3^rd edition. Philadelphia: Saunders, 1992

6  - Friedlander AM, Clinical Aspects, Diagnosis and treatment of Anthrax, J Appl Microbiol 1999; 87(2): 303