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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
When is it a Zebra?
Basic Bioterrorism Response Tools and Connections
Bioterrorism: The Challenge for Family Medicine
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Jacqueline A Frazer, Birmingham, AL Clinical Instructor (resident physician), University of Alabama Birmingham, Thomas Terndrup, Director, Center for Emergency Care and Disaster Preparedness
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The study by Temte and Zinkel provides useful information on alternative diagnoses considered by representative family physicians when inhalational anthrax is being considered in the differential diagnosis. The most common alternative diagnoses were logical and expected to represent severe lung infection in otherwise health patients. The results of the study support that the diagnosis of inhalation anthrax is exceptionally difficult without a high index of suspicion and a compatible history of exposure. Importantly, front line physicians must also consider inhalational anthrax when (1) a single patient has a rapidly progressive or atypical pneumonia and (2) when a series of cases in the same confined area demonstrates unusually severe pneumonia and septicemia. The symptoms of inhalational anthrax are nonspecific leading to a broad differential diagnosis. Seasonal variations in similar syndromes serve to further complicate the diagnosis. The use of broad spectrum, multi- antibiotic regimens is essential when the diagnosis of the critically ill patient is uncertain, and now should include coverage for Bacillus anthracis, when appropriate. Research into further detection methods is warranted. Jacqueline Frazer, M.D. Clinical Instructor (Resident Physician), Department of Emergency Medicine University of Alabama-Birmingham Thomas E. Terndrup, M.D., FACEP Professor and Chair, Department of Emergency Medicine Director, Center for Emergency Care and Disaster Preparedness University of Alabama-Birmingham Competing interests: None declared |
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Jonathan L. Temte, Madison, WI Associate Professor, UW Dept. of Family Medicine
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To the Editor: Dr. Reamy correctly notes that family physicians are likely to contact the initial cases of disease from a covert biological attack. In the primary care arena, however, rare events with non-distinct clinical findings, such as inhalational anthrax, are not likely to be accurately diagnosed at the time of presentation, nor should they be. Over-vigilance can be as harmful as ignorance. That said, maintaining an index of suspicion and some basic tools and connections, as recommended by Dr. Reamy, cannot be overemphasized. Appropriate education of clinicians toward general, evidence-based evaluation and treatment of primary care problems, such as community acquired pneumonia, and ready access to care for all individuals are the most appropriate responses to the challenge presented by bioterrorism. In the cases resulting from the 2001 covert release of anthrax, appropriate management–conducted by unsuspecting physicians–yielded the correct diagnosis in all cases. Following identification of an event, the availability of reliable and succinct information is invaluable. Family physicians are encouraged to maintain contact information for their public health colleagues (see: http://www.aafp.org/btresponse.xml and scroll to “Reporting Info”) and have ready access to readily available information. Jonathan L. Temte, MD/PhD Associate Professor of Family Medicine Competing interests: None declared |
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Brian V. Reamy, Bethesda, MD USA M.D., Colonel, USAF Chair-Dept of Family Medicine, Uniformed Services University
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The threat of a bioterrorist assault on the United States has increased dramatically. Biologic agents are easily available, cheap and possess a high lethality versus other types of terrorist weapons. Indeed, the mere threat of a biologic attack can inspire disproportionate terror. Family Physicians provide the bulk of first contact care in the United States and will be the first physicians to evaluate individuals with the non-specific symptoms that are common in the early phases after a biologic attack. It is crucial that we understand the diagnostic patterns Family Physicians use when evaluating a patient with symptoms from a biologic assault. Temte and Zinkel tackle this question in their article on the Primary Care Differential Diagnosis of Inhalational Anthrax.1 They distributed case vignettes to a nationwide sample of physicians to construct a cluster of 7 likely differential diagnoses that could be used as the sentinel triggers for a public health warning system on anthrax. This research methodology could easily be extended to construct differential diagnoses for the other likely bioterrorist pathogens: smallpox, botulinum toxin, plague, tularemia, staph-toxin B, and ricin. It is crucial that Family Physicians respond to the challenge that bioterrorrism presents. The memorization of signs and symptoms that each pathogen may present are likely to quickly fade from memory and not be useful clinically. Instead, education and familiarization with a general approach to diagnosis and treatment, as well as the maintenance of a catalogue of specific resources is a simple and effective way to respond to this challenge. Cieslak and Henretig offer an elegant and easily remembered general construct entitled; “Ten Commandments of Management” for bio-attack diagnosis and initial treatment.2 This general construct leads the primary care physician through an effective plan from recognition to diagnosis, to early treatment, infection control and public health system notification. Three excellent resources for a physician to keep handy are: phone numbers for the local and state health departments, www.usamriid.army.mil for free access to disease information, treatment, courses and resource books, and www.bt.cdc.gov for disease reporting, consensus statements and news updates. If each of us develops comfort with a general approach and a readily accessible resource list; then the research of Temte and of those to follow will help us lead a public health response to a bioterrorist attack. 1Temte JL, Zinkel AR. The Primary Care Differential Diagnosis of Inhalational Anthrax. Ann Fam Med. 2004;2:438-444. 2 Cieslak TJ, Henretig FM. Medical Consequences of Biologic Warfare: The Ten Commandments of Management. Mil Med. 2001;166:suppl.2:11-12. Competing interests: None declared |
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