Published Date: 2010-01-14 23:00:06
Subject: PRO/AH/EDR> Anthrax - Germany: (NW) fatal, heroin user
Archive Number: 20100114.0170

ANTHRAX - GERMANY: (NORTH RHINE-WESTPHALIA) FATAL, HEROIN USER
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Date: Thu 14 Jan 2010
Source: Eurosurveillance edition 2010; 15(2) [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19464>


Preliminary case report of fatal anthrax in an injecting drug user in
North-Rhine-Westphalia, Germany, December 2009
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[Rapid communications: D Radun et al]

A fatal case of anthrax occurred in an injecting drug user in Germany,
in December 2009. A potential link to similar cases in Scotland in the
same time period is currently under investigation.

The Robert Koch Institute, in collaboration with the Friedrich
Loeffler Institute in Jena, the Federal Research Institute for Animal
Health, and the respective local and regional health authorities in
the Aachen district, North-Rhine-Westphalia, Germany, are currently
investigating a fatal case of anthrax in a 42-year-old male injecting
drug user.

The individual was hospitalised on 6 Dec 2009, complaining of a
swelling of his leg following drug injection into the popliteal fossa
-- reportedly attempting to inject into a vein. He probably injected
heroin, however, details are unknown. Following treatment with
meropenem and surgical debridement of a subsequent necrotising
fasciitis, the patient died with multiorgan failure on 13 Dec 2009.
Anthrax had not been suspected clinically.

Spore-forming bacteria from a wound swab specimen were identified, and
on 18 Dec [2009], the diagnosis of anthrax was confirmed by PCR. The
last case of human anthrax in Germany had been reported in 1994, at
that time affecting a 66-year-old man (1).

At this point in time, it is not clear whether there is a link between
this case and the anthrax outbreak among injecting drug users in
Scotland. As far as we know, the deceased had no travel history to
Scotland. However, it can be assumed that other drug users in the same
area in Germany, or perhaps elsewhere in the country, have been
exposed. In case the hypothesis of a potential link to the Scottish
cases proves true, it might well be that also other countries have
been supplied with contaminated injectable drugs.

We launched an epidemiological investigation and exchanged information
with the colleagues in the United Kingdom and, in particular, Scotland
to coordinate the approach.

So far, the following measures have been taken:
- we have distributed information to public health colleagues, medical
care facilities, and low-threshold facilities in Germany to raise
awareness of the event;
- we are collecting information on the case and his contacts, and on
the substances consumed;
- we attempt further case finding;
- we aim at a microbiological comparison of isolates to establish a
potential epidemiological link with the Scottish cases.

The success of the epidemiological investigation will rely on public
health authorities' efforts, alertness amongst clinicians and medical
microbiologists, but also on the degree to which drug users themselves
can be reached. Therefore, it is of utmost importance to utilise
existing communication channels to inform those who might be at risk.

Reference
---------
1. Robert Koch Institute: Ein Fall von Milzbrand im Land
Niedersachsen. [A case of anthrax in Lower Saxony]. Epid Bull. 1994;
1:10. German.

--
Communicated by:
ProMED-mail
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[It will be interesting to see if there are any links with the
Scottish cases. One may expect, if there are, that it would be an
identical or very similar genotype. I fear that we can now expect more
sick German heroin users. Prior to the 2009 bovine case -- see below
-- there was a bovine infected in August 2000. Prior to that there
were a scattering of bovine and human cases in the early 1990s. -
Mod.MHJ]

[An administrative map of Germany is available at
<http://www.aboutromania.com/maps178.html>.
Aachen can be located on the HealthMap/ProMED-mail interactive map of
Germany at
<http://healthmap.org/r/012E>. - Sr.Tech.Ed.MJ]

See Also

Anthrax - UK (06): (Scotland) 20100113.0149
Anthrax - UK (05): (Scotland) 20100111.0126
Anthrax - UK (04): (Scotland) 20100108.0096
Anthrax - UK (03): Scotland 20100107.0068
Anthrax - UK (02): (Scotland) 20100106.0054
Anthrax - UK: (Scotland) 20100101.0011
2009
----
Anthrax, bovine - Germany: (BY) 20090803.2730
Anthrax, human - UK (04): (Scotland) 20091224.4333
Anthrax, human - United Kingdom (03): (Scotland) 20091222.4317
Anthrax, human - UK (02): (Scotland) 20091219.4288
Anthrax, human - UK: (Scotland) heroin users 20091217.4270
2008
----
Anthrax, human - Germany ex France (02) 20081213.3924
Anthrax, human - Germany ex France 20081211.3897
........................................arn/mhj/mj/jw
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