Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 8) Inhalational Anthrax (See also Chap. 214) Inhalational anthrax, the most severe form of disease caused by Bacillus anthracis, had not been reported in the United States for more than 25 years until the recent use of this organism as an agent of bioterrorism (Chap. 214). Patients presented with malaise, fever, cough, nausea, drenching sweats, shortness of breath, and headache. Rhinorrhea was unusual. All patients had abnormal chest roentgenograms at presentation. Pulmonary infiltrates, mediastinal widening, and pleural effusions were the most common findings. Hemorrhagic meningitis was seen in 38% of these patients. Survival was more likely when antibiotics were given during the prodromal period and if multidrug regimens were used. In the absence of urgent intervention with antimicrobial agents and supportive care, inhalational anthrax progresses rapidly to hypotension, cyanosis, and death. Avian Influenza (H5N1) Infection (See also Chap. 180) Human cases of avian influenza were first reported in Hong Kong. Recent cases have occurred primarily in Southeast Asia, particularly Vietnam. However, evidence of a rapidly expanding geographic distribution of the virus throughout the world is of grave concern. Avian influenza should be considered in patients with severe respiratory tract illness, particularly if they have been exposed to poultry. To date, human-to-human transmission is rare. Patients present with high fever, an influenza-like illness, and lower respiratory tract symptoms. Watery diarrhea may develop and may precede respiratory symptoms. Dyspnea develops a median of 5 days after the onset of symptoms and can progress to respiratory distress syndrome, multiorgan failure, and death within 9– 10 days after the onset of illness. Early antiviral treatment with neuraminidase inhibitors should be initiated along with aggressive supportive measures. Hantavirus Pulmonary Syndrome (See also Chap. 189) Hantavirus pulmonary syndrome (HPS) has been documented in the United States (primarily the southwestern states), Canada, and South America. Most cases occur in rural areas and are associated with exposure to rodents. Patients present with a nonspecific viral prodrome of fever, malaise, myalgias, nausea, vomiting, and dizziness that may progress to pulmonary edema and respiratory failure. HPS causes myocardial depression and increased pulmonary vascular permeability; therefore, careful fluid resuscitation and use of pressor agents are crucial. Aggressive cardiopulmonary support during the first few hours of illness can be life-saving. Conclusion Acutely ill febrile patients with the syndromes discussed in this chapter require close observation, aggressive supportive measures, and—in most cases— admission to intensive care units. The most important task of the physician is to distinguish these patients from other infected febrile patients who will not progress to fulminant disease. The alert physician must recognize the acute infectious disease emergency and then proceed with appropriate urgency. Further Readings Beigel JH et al: Avian influenza A (H5N1) infection in humans. N Engl J Med 353:1374, 2005 [PMID: 16192482] Darouiche RO: Spinal epidural abscess. N Engl J Med 355:2012, 2006 Hasham S et al: Necrotising fasciitis. BMJ 330:830, 2005 [PMID: 15817551] Idro R et al: Pathogenesis, clinical features, and neurological outcome of cerebral malaria. Lancet Neurol 4:827, 2005 [PMID: 16297841] Kyaw MH et al: Evaluation of severe infection and surv ival after splenectomy. Am J Med 119:276.e1, 2006 Nguyen HB et al: Severe sepsis and septic shock: Review of the literature and emergency department management guidelines. Ann Emerg Med 48:28, 2006 Osborn MK, Steinberg JP: Subdural empyema and other sup purative complications of paranasal sinusitis. Lancet Infect Dis 7:62, 2007 Stephens DS et al: Epidemic meningitis, meningococcaemia, and Neisseria meningitidis. Lancet 369:2196, 2007 van de Beek D et al: Community-acquired bacterial meningitis in adults . N Engl J Med 354:44, 2006 Wills BA et al: Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med 353:877, 2005 [PMID: 16135832] Bibliography Anaya DA, Dellinger EP: Necrotizing soft-tissue infection: Diagnos is and management. Clin Infect Dis 44:705, 2007 Annane D et al: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862, 2002 [PMID: 12186604] Bachli EB et al: Drotrecogin alfa (a ctivated) for the treatment of meningococcal purpura fulminans. Intensive Care Med 29:337, 2003 [PMID: 12594601] Bernard GR et al: Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344:699, 2001 [PMID: 11236773] Betrosian AP et al: Purpura fulminans in sepsis. Am J Med Sci 332:339, 2006 Chapman AS et al: Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis— United States: A practical guide for physicians and other health- care and public health professionals. MMWR Recomm Rep 55(RR-4):1, 2006 Cunha BA: Anthrax, tularemia, plague, Ebola or smallpox as agents of bioterrorism: Recognition in the emergency room. Clin Microbiol Infect 8:489, 2002 [PMID: 12197871] Davis DP et al: The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 26:285, 2004 [PMID: 15028325] Ebright JR et al: Septic thrombosis of the cavernous sinuses . Arch Intern Med 161:2671, 2001 [PMID: 11732931] Grewal S et al: Epidural abscesses. Br J Anaesth 96:292, 2006 [PMID: 16431882] Holdty JEC et al: Systematic review: A century of inhalational anthrax cases from 1900 to 2005. Ann Intern Med 144:270, 2006 Holman RC et al: Analysis of risk factors for fatal Rocky Mountain spotted fever: Evidence for superiority of tetracyclines for therapy. J Infect Dis 184:1437, 2001 [PMID: 11709786] Lu CH et al: Strategies for the management of bacterial brain absces s. J Clin Neurosci 13:979, 2006 Miller LG et al: Necrotizing fasciitis caused by community- acquired Staphylococcus aureus in Los Angeles. N Engl J Med 352:1445, 2005 [PMID: 15814880] Norrby-Teglund A et al: Intravenous immunoglobulin adjunctive therapy in sepsis, with special emphasis on severe invasive group A streptococcal infections. Scand J Infect Dis 35:683, 2003 [PMID: 14620155] Oliver JD: Wound infections caused by Vibrio vulnificus and other marine bacteria. Epidemiol Infect 133:383, 2005 [PMID: 15962544] Prentice MB, Rahalison L: Plague. Lancet 369:1196, 2007 Roden MM et al: Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis 41:634, 2005 [PMID: 16080086] Rosenstein NE et al: Meningococcal disease. N En gl J Med 344:1378, 2001 [PMID: 11333996] Stekler J, Collier AC: Primary HIV infection. Curr HIV/AIDS Rep 1:68, 2004 [PMID: 16091225] Tunkel AR et al: Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 39:1267, 2004 [PMID: 15494903] van de Beek et al: Steroids in adults with acute bacterial meningitis: A systematic review. Lancet Infect Dis 4:139, 2004 . Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 8) Inhalational Anthrax (See also Chap. 214) Inhalational anthrax, the most severe form of. cases— admission to intensive care units. The most important task of the physician is to distinguish these patients from other infected febrile patients who will not progress to fulminant disease. The alert. cardiopulmonary support during the first few hours of illness can be life-saving. Conclusion Acutely ill febrile patients with the syndromes discussed in this chapter require close observation,