The use of anthrax as a weapon of biological terrorism has moved from theory to reality in recent weeks. Following processing of a letter containing anthrax spores that had been mailed to a US senator, 5 cases of inhalational anthrax have occurred among postal workers employed at a major postal facility in Washington, DC. This report details the clinical presentation, diagnostic workup, and initial therapy of 2 of these patients. The clinical course is in some ways different from what has been described as the classic pattern for inhalational anthrax. One patient developed low-grade fever, chills, cough, and malaise 3 days prior to admission, and then progressive dyspnea and cough productive of blood-tinged sputum on the day of admission. The other patient developed progressively worsening headache of 3 days' duration, along with nausea, chills, and night sweats, but no respiratory symptoms, on the day of admission. Both patients had abnormal findings on chest radiographs. Non-contrast-enhanced computed tomography of the chest showing mediastinal adenopathy led to a presumptive diagnosis of inhalational anthrax in both cases. The diagnoses were confirmed by blood cultures and polymerase chain reaction testing. Treatment with antibiotics, including intravenous ciprofloxacin, rifampin, and clindamycin, and supportive therapy appears to have slowed the progression of inhalational anthrax and has resulted to date in survival.

Eleven known cases of bioterrorism-related inhalational anthrax (IA) were treated in the United States during 2001. We retrospectively compared 2 methods that have been proposed to screen for IA. The 2 screening protocols for IA were applied to the emergency department charts of patients who presented with possible signs or symptoms of IA at Inova Fairfax Hospital (Falls Church, Virginia) from 20 October 2001 through 3 November 2001. The Mayer criteria would have screened 4 patients (0.4%; 95% CI, 0.1%-0.9%) and generated charges of 1900 dollars. If 29 patients (2.6%; 95% CI, 1.7%-3.7%) with >or=5 symptoms (but without fever and tachycardia) were screened, charges were 13,325 dollars. The Hupert criteria would have screened 273 patients (24%; 95% CI, 22%-27%) and generated charges of 126,025 dollars. In this outbreak of bioterrorism-related IA, applying the Mayer criteria would have identified both patients with IA and would have generated fewer charges than applying the Hupert criteria.

A panel of 10 physicians used the nominal group technique to assess the ability of the Centers for Disease Control and Prevention (CDC) interim guidelines for clinical evaluation of persons with possible inhalational anthrax (IA) to retrospectively identify the 11 patients with IA seen during the October 2001 bioterrorism outbreak. The guidelines would not have identified 10 of 11 of these patients, primarily because the guidelines were designed to address only those patients with a known history of exposure or clearly identified environmental or occupational risk. The panel suggested revisions to the guidelines, primarily consisting of broadening the criteria for evaluation to include either known exposure or environmental occupational risk, or to include clinical symptoms consistent with IA. These extensions of the guidelines retrospectively identified 8 of 11 of the patients with IA from October 2001.

Background: Incidental pulmonary nodules (IPNs) are lung nodules detected on imaging studies performed for an unrelated reason. Approximately 1.6 million IPNs are detected in the United States every year. Unfortunately, close to 1.1 million (69%) of these IPNs are not managed with appropriate follow-up care. The goal of this study was to assess the utility of a noncommercial electronic medical record (EMR)-based IPN keyword recognition program in identifying IPNs and the ability of lung navigators to communicate these findings to patients.Methods: This is a observational, implementation study aimed identify IPNs using an EMR-based protocol and to relay results of findings to patients. The patient population included patients 16 and older undergoing computed tomography (CT) chest, CT chest/abdomen, CT angiogram chest, CT chest/ abdomen/pelvis, and chest radiography through the radiology department within a large community tertiary medical campus between June 2019 and August 2020. EPIC EMR were queried using criteria designed to find IPNs. A lung navigator reviewed these cases and sorted them into categories based on their size and risk status. After identification of risk factors, actions were taken to directly communicate results to patients.Results: Seven hundred and fifty-three patients were found to have true IPNs without a history of active malignancy involving the lung. On the basis of radiographic measurements, 60% of the nodules identified were <6 mm, 17% were between 6 and 8 mm, 22% were > 8 mm, and 12% were deemed nodular opacities. Lung navigators were able to contact a total of 637 (87%) individuals with IPNs and results were directly communicated. Of the 637 patients identified to have an IPN, a total of 12 (2%) cancers were diagnosed. Conclusion:We have here demonstrated that the development of an EMR-based keyword recognition platform for the identification of IPNs is a useful and successful tool for communication of IPN findings to patients using lung navigators.

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