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European cases of heroin-associated anthrax may go undiagnosed
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The intermittent re-emergence of anthrax among heroin users in Europe may warrant blood testing surveillance of injection drug users who present with sepsis or soft tissue infection, according to recent findings.
In a report published in Emerging Infectious Diseases, researchers chronicled the heroin-associated anthrax cases seen during an outbreak in England and Scotland in 2009-2010, as well as a subsequent outbreak in 2012-2013 in northern Europe and Germany.
The first two heroin-related anthrax cases were reported on Dec. 10, 2009, in the Greater Glasgow and Clyde area of Scotland. This number increased to 47 confirmed patients in Scotland by July 2010, 13 of whom died. Additionally, cases began to be reported in January 2010 in England and Germany. In England, six cases and four deaths were reported before the outbreak was declared over Dec. 23, 2010.
Twenty-one months after the last case seen in England’s outbreak, a fatal case of heroin-associated anthrax was identified in Regensburg, Bavaria, Germany. By March 2013, seven more cases were reported in the United Kingdom, with five in England. There were four deaths during this outbreak; two patients in England, one in Scotland and one in Wales.
Before these outbreaks, the only reported case of heroin-associated anthrax was seen in 2000 in an injection drug user in Norway. This patient ultimately developed fatal hemorrhagic encephalitis.
In the 2009-2010 outbreaks, patients most frequently presented with localized, injection-site abscesses or inflammatory lesions.
These recurring outbreaks in Europe indicate that batches of heroin contaminated with anthrax may still be in circulation, underscoring the need for watchfulness in the injection drug user population.
Antibiotics used to treat serious soft tissue infection are effective against anthrax and may inadvertently mask a significant number of heroin-associated anthrax cases, the researchers noted.
“Given the novel nature of the clinical manifestation, clinicians may not consider anthrax in the differential diagnosis of severe infections in [injection drug users], resulting in undiagnosed cases,” the researchers wrote. “Clinical awareness of the associated risk for injection-related infection by rare pathogens in this population is therefore crucial, particularly because the range of clinical manifestation is broad.”
Disclosure: The researchers report no relevant financial disclosures.
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