[Visceral form of human anthrax imported from Africa]

Widespread vaccination has largely eliminated anthrax in Europe (the last case was reported in France in 1972) but the disease remains endemic in many developing countries. The usual cutaneous presentation (malignant pustules) is much more familiar than the various visceral manifestations including digestive tract, pulmonary or meningeal signs. We report a case of a 33-year-old immigrant living in France who was hospitalized for asthenia, dyspnoea, mucopurulant expectoration and moderate diarrhoea 3 days after a 3-month stay in Senegal and Gambia. The temperature was 39 degrees C at admission and blood pressure 110/70 mmHg. Crepitants were heard at the base of the right lung and the rest of the physical examination was normal. Blood was drawn for culture. Laboratory tests and the chest X-ray led to the diagnosis of pneumopathy and a treatment of amoxicillin and clavulanic acid was given with oxygenotherapy. The patient's temperature returned to normal but over the next 48 hours the dyspnoea worsened together with the black diarrhoea. The abdomen was painful. There were no skin lesions. The chest X-ray revealed an extension of the bilateral pulmonary images and bilateral pleural effusion. Laboratory tests revealed thrombopenia (platelet count 38,000/mm3) hyperleukocytosis (WBC 48,000/mm3) and haemolysis (Hb 4 milligrams). The diagnosis was made on the basis of the initial blood cultures which were positive for Bacillus anthracis. All other samples were negative, including HIV serology. Despite adapted antibiotic therapy (penicillin G, 8MU/day, was initiated on day 2), multiple organ failure occurred with septic shock and pulmonary oedema. The patient died in the intensive care unit on day 7. Fatal outcome due to anthrax is described in 25% of the visceral forms but reaches 100% in cases of septicaemia. The haemolysis observed in this case is not mentioned in the classical descriptions of anthrax. When treating septic syndromes in patients who have returned from endemic zones, clinicians should entertain the diagnosis of anthrax since the risk of fatal outcome is increased greatly in case of delayed diagnosis.