Inhalational anthrax in a vaccinated soldier

To the Editor: The spore-forming bacterium, Bacillus anthracis , primarily affects herbivores but can manifest as cutaneous (>95% of cases), gastrointestinal or pulmonary infection in humans. Pulmonary anthrax, resulting from inhalation of anthrax spores, is rapidly progressive and historically was considered to be invariably fatal. Clinical features include haemorrhagic thoracic lymphadenitis, pulmonary oedema, pleural effusions, leptomeningeal involvement, septic shock and respiratory distress, with death often following within 24 h [1, 2]. Due to the high mortality and potential for use as a biological agent, anthrax vaccines were developed in the 1950s [3]. B. anthracis is composed of three proteins known as protective antigen (PA), oedema factor and lethal factor (LF), with PA named after its ability to provide experimental immunity. Anthrax vaccines demonstrated protection against cutaneous anthrax in tannery workers [3] and vaccination protected rhesus monkeys from inhalational anthrax for up to 2 years [4]. No adequately powered studies exist that demonstrate protection by the vaccine against inhalational anthrax in humans. Despite this, widespread vaccination of military personnel was undertaken by allied forces during the recent Gulf Wars [5]. We present a case of initially unrecognised, inhalational anthrax in a vaccinated member of the armed forces. A 38-year-old male presented with severe, sudden-onset central chest pain at rest, which was associated with nausea and dizziness. He denied shortness of breath. His past medical history included a “supraclavicular lymph node infection” aged 18 years. He was previously fit and well, apart from an undiagnosed painful right knee sustained in the …