Anthrax

Anthrax

Zoonotic disease caused by Bacillus anthracis Described in biblical times 1500 B.C - A plague of boils in Egypt affected the Pharaohs cattle 1600s - The Black Bane thought to be anthrax, in Europe kills over 60,000 cattle

1876 - German bacteriologist Robert Koch confirmed bacterial origin of anthrax

1881 - First animal vaccine developed by Louis Pasteur 2001 - Used for bioterrorism

Anthrax

Zoonotic disease in herbivores (e.g., sheep, goats, cattle), follows ingestion of spores in soil Human infection acquired through contact with anthrax-infected animals or animal products or through intentional exposure Three clinical forms Cutaneous Inhalational Gastrointestinal

Three forms of Anthrax

Cutaneous anthrax Skin Most common Spores enter to skin through small lesions Inoculation: through an open wound in the skin.

Inhalation anthrax Spores are inhaled

Route has the Highest Mortality

Gastrointestinal (GI) anthrax Spores are ingested by eating contaminated meat Oral-pharyngeal and abdominal

Bacillus anthracis

Large (1-1.5 X 3-10 m) Gram-positive Spore forming Aerobic and facultative anaerobic Non motile Rod shaped bacteria

Endospore

Endospores may remain viable in soil for years Oxygen required for sporulation 1 spore per cell dehydrated cells Highly resistant to heat, cold, chemical disinfectants, dry periods Protoplast carries the material for future vegetative cell Cortex provides heat and radiation resistance Spore wall provides protection from chemicals & enzymes

http://www.gsbs.utmb.edu/microbook/ch015.htm

Pathogenesis

Bacterial capsule: preventing phagocytosis & prevents lysis. 2 toxins: lethal toxin, edema toxin. Protective antigen (83-kd protein)
Main protective antigen constituent of anthrax vaccines Binds to target receptors, loses 20-kd fragment.

Capsule

Glycocalyx Sticky, gelatinous polymer external to cell wall

pX02 plasmid
Made up of D-glutamic acid Non-toxic on its own Only encapsulated B. anthracis virulent Most important role during establishment of disease Protects against phagocytosis & lysis during vegetative state

http://textbookofbacteriology.net/BSRP.html

Pathophysiology
Edema Factor (89 Kd protein) Protective Antigen (83 Kd protein) Lethal Factor (90 Kd protein)

Edema Toxin

Lethal Toxin

Increased c-AMP Tissue edema

Macrophage lysis

Release Tumor Necrosis Factor

Inhibit WBC phagocytosis

Mechanism of Infection

Anthrax spores enter body Germinate & multiple in lymph nodes PA, EF, LF excreted from bacteria PA binds to TEM8. PA nicked by protease furin 20-kDa segment off leaving 63kDa peptide Heptamer forms EF and/or LF binds Complex internalized by endocytosis Acidification of endosome LF or EF crosses into cytosol via PA mediated ion-conductive channels LF cleaves MAPKK 1 & 2 EF stimulates cAMP

http://kugi.kribb.re.kr/KUGI/Pathways/BioCarta/anthraxPathway/

Outcome

EF converts ATP to cAMP

Increases cAMP levels over 1,000 fold Impairs neutrophil function Alters water homeostasis Edema

LF cleaves MAPKK at its N terminus

Disrupts pathways involved in cell growth & maturation Increased synthesis of tumor necrosis factor- & interleukin-1 Macrophage lysis More cells infected with bacteria & toxin Septic shock & death

Toxins

pX01 plasmid AB model Binding Activating Protective antigen (PA), edema factor (EF) & lethal factor (LF) Make up 50% of proteins in the organism Individually non-toxic PA+LF lethal activity EF+PA edema EF+LF inactive PA+LF+EF edema & necrosis; lethal

http://www.rcsb.org/pdb/molecules/pdb28_1.html

Toxins (2)

Protective antigen (PA, 83kDa) Pag gene Binds to receptor & helps internalize other 2 proteins Edema factor (EF, 89 kDa) Cya gene Adenylate cyclase Affects all cells Lethal factor (LF, 87 kDa) Lef gene More important virulence factor Metalloprotease Cleaves mitogen activated protein kinase kinsase (MAPKK) Affects only macrophages

http://www.ericse.org/anthrax/anthraxmicrographs.html

Anthrax Pathogenesis

Spores enters through broken skin or mucous membranes Germinate in macrophages, replicate in lymph nodes and intracellular space Bacteria produce antiphagocytic capsule Production of toxins cause tissue destruction and edema

Three clinical forms of Anthrax

Three

clinical forms

cutaneous (most common in natural exposure situations) gastrointestinal (rare)

inhalation

Cutaneous Anthrax

95% of anthrax infections occur when the bacterium enters a cut or scratch on the skin due to handling of contaminated animal products or infected animals. May also be spread by biting insects that have fed on infected hosts. After the spore germinates in skin tissues, toxin production initially results in itchy bump that develops into a vesicle and then painless black ulcer.

http://science.howstuffworks.com/anthrax1.htm

Cutaneous Anthrax

The most common naturally occurring form of anthrax.

Ulcers are usually 1-3 cm in diameter.

Incubation period: Usually an immediate response up to 1 day Eschar sloughs after 2-3 weeks. Fever, H/A, malaise, regional lymphadenopathy Fatality rate: 5-20% untreated <1 % if treated Antibiotics prevent dissemination not local skin lesion
Source:WHO

Gastrointestinal Anthrax

GI anthrax may follow after the consumption of contaminated, poorly cooked meat. There are 2 different forms of GI anthrax: 1) Oral-pharyngeal 2) Abdominal

Abdominal anthrax is more common than the oralpharyngeal form.

http://science.howstuffworks.com/anthrax1.htm

GI Anthrax (2)

Oral-pharyngeal form - results from the deposition and germination of spores in the upper gastrointestinal tract. Local lumphadenopathy (an infection of the lymph glands and lymph channels), edema, sepsis develop after an oral or esophageal ulcer. Abdominal form - develops from the deposition and germination of spores in the lower gastrointestinal tract, which results in a primary intestinal lesion. Intestinal involvement includes abdominal pain, fever, bloody vomiting or diarrhea

GI Infection (3)

GI anthrax cases are uncommon. There have been reported outbreaks in Zimbabwe, Africa and northern Thailand in the world. GI anthrax has not been reported in the US. Incubation period: 1-7 days Case fatality at 2 days of infection: Untreated (25-60%) With antimicrobial therapy (undefined) due to the rarity

Inhalation Anthrax

The infection begins with the inhalation of the anthrax spore. Spores need to be less than 5 microns (millionths of a meter) to reach the alveolus. Macrophages lyse and destroy some of the spores. Survived spores are transported to lymph nodes.

At least 2,500 spores have to be inhaled to cause an infection.

Inhalation Anthrax, Introduction, DRP, Armed Forces Institute of Pathology

Inhalation Anthrax (2)

Disease immediately follows germination. Spores replicate in the lymph nodes. The two lungs are separated by a structure called the mediastinum, which contains the heart, trachea, esophagus, and blood vessels. Bacterial toxins released during replication result in mediastinal widening and pleural effusions (accumulation of fluid in the pleural space).

Inhalation Anthrax, Introduction, DRP, Armed Forces Institute of Pathology

Inhalation Anthrax (3)

Death usually results 2-3 days after the onset of symptoms. Natural infection is extremely rare (in the US, 20 cases were reported in last century). Inhalation Anthrax is the most lethal type of Anthrax. Incubation period: 17 days Possibly ranging up to 60 days (depending on how many spores were inhaled). Case fatality after 2 days of infection: Untreated (97%) With antimicrobial therapy (75%)

How is anthrax diagnosed?

Gram stain Culture of B. anthracis from the blood, skin lesions, vesicular fluid, or respiratory secretions X-ray and Computed Tomography (CT) scan Rapid detection methods - PCR for detection of nucleic acid - ELISA assay for antigen detection - Other immunohistochemical and immunoflourescence examinations

Treatment

Before 2001, 1st line of treatment was penicillin G Stopped for fear of genetically engineered resistant strains 60 day course of antibiotics Ciprofloxacin fluoroquinolone 500 mg tablet every 12h or 400 mg IV every 12h Inhibits DNA synthesis Doxycycline 6-deoxy-tetracycline 100 mg tablet every 12h or 100 mg IV every 12h Inhibits protein synthesis For inhalational, need another antimicrobial agent clindamycin rifampin chloramphenicol

http://nmhm.washingtondc.museum/news/anthrax.html

Anthrax Vaccine

Cell-free culture filtrate of toxigenic strain of B. anthracis Filtrate contains protective antigen (PA) and other cellular products Adsorbed to aluminum hydroxide as an adjuvant Contains small amounts of benzethonium chloride (preservative) and formaldehyde (stabilizer)

Anthrax Vaccine