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A Systematic Review of Cases: 1900 to 2005

Dena M. Bravata, MD, MS; Jon-Erik C. Holty, MD, MS; Ewen Wang, MD; Robyn Lewis, MA; Paul H. Wise, MD, MPH; Kathryn M. McDonald, MM; Douglas K. Owens, MD, MS

Arch Pediatr Adolesc Med. 2007;161(9):896-905.

Objective  To systematically review all published case reports of children with anthrax to evaluate the predictors of disease progression and mortality.

Data Sources  Fourteen selected journal indexes (1900-1966), MEDLINE (1966-2005), and the bibliographies of all retrieved articles.

Study Selection  Case reports (any language) of anthrax in persons younger than 18 years published between January 1, 1900, and December 31, 2005.

Main Exposures  Cases with symptoms and culture or Gram stain or autopsy evidence of anthrax infection.

Main Outcome Measures  Disease progression, treatment responses, and mortality.

Results  Of 2499 potentially relevant articles, 73 case reports of pediatric anthrax (5 inhalational cases, 22 gastrointestinal cases, 37 cutaneous cases, 6 cases of primary meningoencephalitis, and 3 atypical cases) met the inclusion criteria. Only 10% of the patients were younger than 2 years, and 24% were girls. Of the few children with inhalational anthrax, none had nonheadache neurologic symptoms, a key finding that distinguishes adult inhalational anthrax from more common illnesses, such as influenza. Overall, observed mortality was 60% (3 of 5) for inhalational anthrax, 65% (13 of 20) for gastrointestinal anthrax, 14% (5 of 37) for cutaneous anthrax, and 100% (6 of 6) for primary meningoencephalitis. Nineteen of the 30 children (63%) who received penicillin-based antibiotics survived, and 9 of the 11 children (82%) who received anthrax antiserum survived.

Conclusions  The clinical presentation of children with anthrax is varied. The mortality rate is high in children with inhalational anthrax, gastrointestinal anthrax, and anthrax meningoencephalitis. Rapid diagnosis and effective treatment of anthrax in children requires recognition of the broad spectrum of clinical presentations of pediatric anthrax.

Author Affiliations: Center for Primary Care and Outcomes Research, Stanford University (Drs Bravata, Holty, Wise, and Owens and Mss Lewis and McDonald), and Division of Pulmonary and Critical Care Medicine (Dr Holty) and Departments of Surgery (Emergency Medicine) (Dr Wang) and Pediatrics (Dr Wise), Stanford University Medical Center, Stanford, California; and VA Palo Alto Health Care System, Palo Alto, California (Dr Owens).