Case presentation
A 27 year old male from south-eastern state of India presented with fever and progressive pain and cellulitis of right eye for one week. There was no history of vomiting, altered mentation or seizure episodes associated with his symptoms. He did not have any respiratory symptoms as well. Initially he developed fever and noticed a small papule below his right eye. It soon progressed and developed cellulitis involving the entire periorbital area. There was also watering from the affected eye and he was not able to open it. Fever intensity was increased progressively and was 102.7 degree fahrenheit on admission. He was initially evaluated under dermatology and a biopsy from the erythematous eschar like induration was performed. He was transferred under infectious disease department and was evaluated further. Baseline blood counts showed total WBC count of 19,300/microlt. with 87 % neutrophils. He also had elevated CRP and ESR of 47.1 mg/dl and 117 mm per hour respectively. Two large volume blood cultures were sent and was started on injection meropenem empirically based on his clinical condition.
On detailed history from his family members, it was revealed that he skinned a goat in a family feast one week before his symptoms started. Other family members were not present at the time of skinning but they ate the meat. None of them developed any symptom. Microbiology laboratory was alerted about proper precautionary measures during handling of samples. With this classical history; cutaneous anthrax was strongly suspected and urgent CSF study was done to rule out meningeal involvement. CSF showed 3 cells/cu mm with normal protein of 37 mg/dl and glucose of 78 mg/dl. CSF Gram stain was negative and culture was sterile. He did not have lung symptoms and chest x-ray was also normal. Skin biopsy from the eschar like lesion showed neutrophilic inflammation. Initial biopsy was done under dermatology and only histopathology was sent as anthrax was not considered in the differential diagnosis as it is rarely seen nowadays. The tissue was already processed in formalin, culture could not be done and immunohistochemistry was performed from the sample. It showed Gram positive bacilli resembling Bacillus anthracis (Fig. 1). All his blood cultures came as negative and his antimicrobial was deescalated to ciprofloxacin initially intravenous later as oral. He improved considerably with therapy and was discharged. He was followed up in OPD basis and progressive improvement of eye lesions was seen after 1 month and 2 months (Fig. 2A–C).
Fig. 1.
Immunohistochemical staining showed bacilliform antigen (red arrows) stained with anti-Bacillus anthracis cell wall antibody (Magnification - X250).
Fig. 2.
A) Baseline image showing extensive cellulitis of right periorbital area and area of skin biopsy marked with arrow, B) After one month of therapy - cellulitis resolved with 2.5 * 1.5 cm scab below the right eye, C) Image after 2 months of therapy - complete resolution of cellulitis and scab fallen off.
Cutaneous anthrax is much less common now a days and notifiable disease around the world. Specific risk factors of animal exposure is often associated with it. Isolated eyelid and periorbital involvement is very rare in tropical countries with only few cases reported in literature [1], [2]. Detailed history of animal exposure should be taken when suspected. Timely treatment with ciprofloxacin [3] prevents progression to disseminated disease involving brain and other organs.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Author contribution
Dipankar Pal: study design, data collections, data analysis, writing, Literature search. Adrian Keith Noronha: data collections and writing. Selwyn Selva Kumar D: study design, data analysis.
Ethical approval
Received.
Funding
No funding received from any individual or organisation.
Conflict of interest
There is no conflict of interest.
References
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