1) An outbreak of anthrax killed at least 68 people in Sverdlovsk, Russia in 1979 after accidental release from a Soviet bioweapons facility. 2) In October 2001, 10 cases of inhalational anthrax were diagnosed in the United States following the intentional release of anthrax spores through the mail system. 3) Symptoms of inhalational anthrax usually appear within 7 to 10 days of exposure and can include fever, fatigue, cough, nausea, difficulty breathing, and chest pain. Without prompt treatment with antibiotics, inhalational anthrax is often fatal.

1. Modified from N.Y. Dept. of Health
Anthrax is Diagnosed: Day 10
Click for larger picture

2. Anthrax as a Biological Weapon
(JAMA. 1999; 281:1735-1745)
Figure 4. Day of Onset of Inhalational Anthrax
Following Sverdlovsk Accident
Figure is based on data from Guillermin.68

3. (JAMA. 1999; 281:1735-1745)
This curve approximates that of the accumulated deaths more closely
Anthrax is Diagnosed: Day 10
Click for larger picture

4. Lidia Tretyakova looks at the tombstone of her father, Lazar Karsayev, at a
cemetery in Yekaterinburg, Russia, Thursday, Oct. 18, 2001. A mysterious outbreak
of anthrax killed at least 68 people, including Karsayev, 22 years ago in the Russian
industrial center of Sverdlovsk, today known as Yekaterinburg. At the time, neither
the victims nor their families suspected they had been hit by a biological weapon.

6. Laboratory workers at the Sverdlovsk regional epedemiological
service put on the special suits they wear when working with
anthrax and other dangerous bacteria in Yekaterinburg, Russia,
Wednesday, Oct. 17, 2001

7. A general view of the Stepnogorsk Scientific Experimental and
Production Base (SEPB) in Stepnogorsk, 220 km (100 miles)
northwest of Kazakstan's new capital of Astana, Monday, Oct. 22,
2001. The SEPB was the biggest anthrax-manufacturing plant in

8. Scientists work in an environmental monitoring laboratory of
Stepnogorsk Scientific Experimental and Production Base (SEPB)
in Stepnogorsk, 220 km ( 100 miles) northwest of Kazakstan's
new capital of Astana, Monday, Oct. 22, 2001. The SEPB was the
biggest anthrax-manufacturing plant in the world. (AP Photo)

9. J.A.M.A.1979. 281: 1735-1745. Working Group on Civilian Biodefense
Review of some Consensus guidelines

10. J.A.M.A.1979. 281: 1735-1745. Working Group on Civilian Biodefense
Click for larger picture

11. Ratified in MMWR. 2001. 50: 889-897. (Oct. 19, 2001)
J.A.M.A.1979. 281: 1735-1745. Working Group on Civilian Biodefense
Click for larger picture

12. The recent Anthrax victims
The victims of the recent terrorist
use of anthrax bacilli started to
appear in October 2001. On
October 2 the spinal fluid of a
patient in Miami showed large
Gram positive bacilli, confirmed on
October 4 as Bacillus anthracis

13. Ottilie Lundgren, 94
Inhaled
Connecticut farm
Died, Nov.21, 2001
List of recent
bioterrorism-
related Anthrax
victims
Inhalational Patients
Recovered
Died
Norma Wallace, 56

14. CONFIRMED BIOTERRORISM-RELATED INHALATIONAL ANTHRAX PATIENTS
General demographic data Symp- First Hospi- Conf. Diagnostic means providing End
No. Age Eth Sex Place toms Seen talized Diag. POSITIVE Anthrax result Res.
1 63 C M Am.Media Boca Ratón 27/09 02/10 02/10 04/10 CSF: Gram+Culture 05/10
2 73 H M Am.Media Boca Ratón 24/09 28/07 01/10 15/10 Nose Culture; Pleural fluid PCR 23/10
3 56 AA M Brentwood D.C. Mail 16/10 19/10 19/10 21/10 Blood culture 11/11
4 56 AA M Brentwood D.C. Mail 16/10 20/10 20/10 22/10 Blood culture 09/11
5 55 AA M Brentwood D.C. Mail 16/10 18/10 21/10 23/10 Blood culture-ImmHist: Systemic 21/10
6 47 AA M Brentwood D.C. Mail 16/10 20&22/10 22/10 23/10 Blood culture-ImmHist: Systemic 22/10
7 59 C M State Dep. D.C. Mail 22/10 24/09 25/10 25/10 Blood culture 09/11
8 56 AA F Hamilton N.J. Mail 14/10 19/10 19/10 28/10 Blood culture-PCR-ImmHist CWall, Capsule 05/11
9 43 SA F Hamilton N.J. Mail 15/10 16/10 18/10 30/10 Pleural fluid ImmHistCh: Cell Wall, Capsule 26/10
10 61 A F Eye Ear Throat Manhattan 25/10 28/10 28/10 30/10 Blood culture-ImmHist: Systemic 31/10
11 94 C F Oxford, Connecticut farm 11/11 17/11 17/11 20/11 Blood culture - Later PCR 21/11
Numbers as in Jernigan et al. 2001 COLORS and Outcome* CSF: Cerebrospinal Fluid
Eth: Ethnicity Died PCR: Polymerase Chain Reaction
H: Hispanic Survived ImmHist or ImmHistCh: Immunohistochemistry
AA: Afroamerican *End Res.: End Result CWall: Cell Wall
C: Caucasic
A: Asian
More illustrations
Data mostly from Jernigan et al., Emerging Infectious Diseases, 7: 933-944, 2001
Patient No. 11 is not presented in the Jernigan series; the data appeared in the news.
Click for larger picture

22. Timeline of 10 cases of inhalational anthrax in relation
to onset of symptoms, October through November 2001
Jernigan et al., Emerging Infectious Diseases, 7: 933-944, 2001
Click for larger picture

23. Symptoms for 10 patients with bioterrorism-related
inhalational anthrax, October-November 2001
Symptoms n=10
Fever, chills 10
Fatigue, malaise, lethargy 10
Cough (minimally or nonproductive) 9
Nausea or vomiting 9
Dyspnea 8
Sweats, often drenching 7
Chest discomfort or pleuritic pain 7
Myalgias 6
Headache 5
Confusion 4
Abdominal pain 3
Sore throat 2
Rhinorrhea 1
Table 2, Jernigan et al., 2001. Emerging Infectious Diseases, 7: 933-944.

24. Initial clinical findings in 10 patients with bioterrorism-
related inhalational anthrax, October-November 2001
Physical findings
Fever (>37.8C) 7/10
Tachycardia (heart rate >100/min) 8/10
Hypotension (systolic blood pressure 1/10
<110 mm Hg)
Laboratory results
White blood cell count (median, range) 9.8 x 103
/mm3
Differential - neutrophilia (>70%) 7/10
Neutrophil band forms (>5%) '4/5
Elevated transaminasesa
9/10
(SGOT or SPGT > 40) 7/10
Hypoxemia 6/10
(Alveolar-arterial oxygen gradient >30 mm
Hg on room air O2 saturation <94%)
Metabolic acidosis 2/10
Elevated creatinine (>1.5 mg/dL) 1/10
Chest X-ray findings
Any anormality 10/10
Mediastinal widening 7/10
Infiltrates/consolidation 7/10
Pleural effusion 8/10
Chest computed tomography findings
Any anormality 8/8
Mediastinal lymphadenopathy, widening 7/8
Pleural effusion 8/8
Infiltrates/consolidation 6/8
a
SGOT = serum glutamic oxalacetic transaminase;
SGPT = serum glutamic pyruvic transaminase
Table 3,
Jernigan et al.,
2001.
Emerging
Infectious
Diseases,
7: 933-944.
Click for
larger
picture

25. Initial chest X-ray, Case 1 – Prominent upper mediastinum

26. Gram stain, cerebrospinal fluid, Case 1  Clear diagnosis, Oct. 2, 2001

27. Chest X-ray, Case 2 –
Diffuse consolidation,
consistent with
pneumonia of left lung
No mediastinal
widening

28. Computed
tomography
of chest,
Case 2
Bilateral
pulmonary
consolidation
and pleural
effusioins

29. Chest X-ray, Case 7 – Mediastinal widening, left pleural effusion

30. Chest computed tomography, Case 7 –
Mediastinal adenopathy, bilateral pleural effusions