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Volume 20, Number 7—July 2014

Lessons for Control of Heroin-Associated Anthrax in Europe from 2009–2010 Outbreak Case Studies, London, UK

Aula Abbara, Tim Brooks, Graham P. Taylor, Marianne Nolan, Hugo Donaldson, Maribel Manikon, and Alison HolmesComments to Author 
Author affiliations: Imperial College Healthcare National Health Service Trust, London, UK (A. Abbara, G.P. Taylor, M. Nolan, H. Donaldson, M. Manikon, A. Holmes); Public Health England, Porton Down, UK (T. Brooks)

Main Article


Details of 3 heroin-associated anthrax patients from the 2009–2010anthraxoutbreak, London, United Kingdom*

Patient 1
Patient 2
Patient 3
Age, y/sex
HIV, hepatitis C
Hepatitis B, hepatitis C, thromboembolic disease
Hepatitis C, left femoral artery pseudoaneurysm
Route of infection
Subcutaneous injection to left thigh 3 d before admission
Subcutaneous injection to right buttock 1 wk before admission
Injected into left femoral artery
Site affected when patient sought treatment
Extensive involvement: painless edema and blistering of the left thigh, lower abdomen, genitals
Right buttock erythematous, swollen, edematous, and painful; edema extended to genitals
Pulsatile mass at left groin area; no edema or swelling evident
Extensive debridement by general surgery and gynecology performed on 2 occasions; skin graft applied later
Early, limited debridement performed on d 1 of hospitalization. Skin graft applied later
On hospital d 1, surgery performed to repair left femoral artery pseudoaneurysm and debridement; further debridement performed at d 19
Anthrax testing results
Culture Blood culture of specimen drawn on admission positive in <24 h Blood and tissue cultured on admission positive 24 h after admission Blood and tissue cultured on admission negative
Serologic Positive Positive Positive
Initial antibiotic drugs
Ceftriaxone, clindamycin, vancomycin
Clindamycin, ciprofloxacin, flucloxacillin, vancomycin, gentamicin
Clindamycin, ciprofloxacin, flucloxacillin, benzylpenicillin, metronidazole
Initially lucid and comfortable but hemodynamically unstable. Debridement on 2 occasions. Anthrax PCR post–antibiotic drug treatment negative; coagulopathy resolved by day 29 with normal platelets and clotting studies. On day 31, brain stem ischemia developed; died on d 50 after airway complications.
After initial debridement, electively intubated to treat edema causing respiratory compromise. Received AIGIV within 24 h of admission. Vacuum-assisted therapy pump was used, then skin graft, with good outcome. Recovered and was discharged to complete 60 d of ciprofloxacin and clindamycin.
After first surgery on hospital d 1, continued broad-spectrum antibiotic drugs for 10 d. Received a further 14 d of broad-spectrum antibiotic drugs after debridement on d 19. Made a good recovery and was discharged home. Strongly positive serologic results subsequently received.
Test results for blood samples taken at admission (reference range)†
Leukocyte count (4.2–11.2 x 109 L) 23.1 16.8 10.1
Neutrophils (2.0–7.1 x 109/L) 14.6 14.6 4.9
CRP (0–4 mg/L) 179 71 230
Hemoglobin (13.0–16.8 g/dL) 15.7 6.7 9.8
INR (1.0) 4.4 1.5 1.0
Platelets (130–370 x 109/L) 374 30 238
Creatinine (60–125 μmol/L) 385 488 137
Albumin (30–45 g/L) 24 23 30

*Patients 1, 2, and 3 represent the diversity of the cases seen and the spectrum of manifestation caused by heroin-associated anthrax. Clinical features associated with this condition include the degree of edema present, the absence of the eschar associated with cutaneous anthrax, and the biphasic nature of the illness; in the severe cases, Patients 1 and 2 experienced multiorgan dysfunction and coagulopathy. AIGIV, anthrax immune globulin intravenous; CRP, C-reactive protein; INR, international normalized ratio.
†Reference ranges from Imperial College Healthcare (

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Page created: June 12, 2014
Page updated: June 12, 2014
Page reviewed: June 12, 2014
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