Pulmonary tuberculosis TB; Tuberculosis - pulmonary Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs,

but may spread to other organs. Causes, incidence, and risk factors Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis (M. tuberculosis). You can get TB by breathing in air droplets from a cough or sneeze of an infected person. This is called primary TB. In the United States, most people will recover from primary TB infection without further evidence of the disease. The infection may stay inactive (dormant) for years. However, in some people it can reactivate. Most people who develop symptoms of a TB infection first became infected in the past. However, in some cases, the disease may become active within weeks after the primary infection. The following people are at higher risk for active TB:

Elderly Infants People with weakened immune systems, for example due to AIDS, chemotherapy, diabetes, or certain medications

Your risk of contracting TB increases if you:

Are in frequent contact with people who have TB Have poor nutrition Live in crowded or unsanitary living conditions

The following factors may increase the rate of TB infection in a population:

Increase in HIV infections Increase in number of homeless people (poor environment and nutrition) The appearance of drug-resistant strains of TB

In the United States, there are approximately 10 cases of TB per 100,000 people. However, rates vary dramatically by area of residence and socioeconomic status.

Symptoms The primary stage of TB usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include:

Cough (usually cough up mucus) Coughing up blood Excessive sweating, especially at night Fatigue Fever Unintentional weight loss

Other symptoms that may occur with this disease:

Breathing difficulty Chest pain Wheezing

Signs and tests The doctor or nurse will perform a physical exam. This may show:

Clubbing of the fingers or toes (in people with advanced disease) Swollen or tender lymph nodes in the neck or other areas Fluid around a lung (pleural effusion) Unusual breath sounds (crackles)

Tests may include:

Biopsy of the affected tissue (rare) Bronchoscopy Chest CT scan Chest x-ray Interferon-gamma blood test such as the QFT-Gold test to test for TB infection Sputum examination and cultures

Thoracentesis Tuberculin skin test (also called a PPD test)

Treatment The goal of treatment is to cure the infection with drugs that fight the TB bacteria. Treatment of active pulmonary TB will always involve a combination of many drugs (usually four drugs). All of the drugs are continued until lab tests show which medicines work best. The most commonly used drugs include:

Isoniazid Rifampin Pyrazinamide Ethambutol

Other drugs that may be used to treat TB include:

Amikacin Ethionamide Moxifloxacin Para-aminosalicylic acid Streptomycin

You may need to take many different pills at different times of the day for 6 months or longer. It is very important that you take the pills the way your health care provider instructed. When people do not take their TB medications as recommended, the infection may become much more difficult to treat. The TB bacteria may become resistant to treatment, and sometimes, the drugs no longer help treat the infection. When there is a concern that a patient may not take all the medication as directed, a health care provider may need to watch the person take the prescribed drugs. This is called directly observed therapy. In this case, drugs may be given 2 or 3 times per week, as prescribed by a doctor. You may need to stay at home or be admitted to a hospital for 2 - 4 weeks to avoid spreading the disease to others until you are no longer contagious.

Your doctor or nurse is required by law to report your TB illness to the local health department. Your health care team will be sure that you receive the best care for your TB. Support Groups You can ease the stress of illness by joining a support group where members share common experiences and problems. See: Lung disease - support group Expectations (prognosis) Symptoms often improve in 2 - 3 weeks. A chest x-ray will not show this improvement until weeks or months later. The outlook is excellent if pulmonary TB is diagnosed early and treatment is begun quickly. Complications Pulmonary TB can cause permanent lung damage if not treated early. Medicines used to treat TB may cause side effects, including liver problems. Other side effects include:

Changes in vision Orange- or brown-colored tears and urine Rash

A vision test may be done before treatment so your doctor can monitor any changes in your eyes' health over time. Calling your health care provider Call your health care provider if:

You have been exposed to TB You develop symptoms of TB Your symptoms continue despite treatment New symptoms develop

Prevention TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative. A positive skin test means you have come into contact with the TB bacteria. Talk to your doctor about how to prevent getting tuberculosis. Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB. Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is limited and it is not routinely used in the United States. People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor.

Diphtheria Diphtheria is an acute infectious disease caused by the bacteria Corynebacterium diphtheriae. Causes, incidence, and risk factors Diphtheria spreads through respiratory droplets (such as those produced by a cough or sneeze) of an infected person or someone who carries the bacteria but has no symptoms. Diphtheria can also be spread by contaminated objects or foods (such as contaminated milk). The bacteria most commonly infects the nose and throat. The throat infection causes a gray to black, tough, fiber-like covering, which can block the airways. In some cases, diphtheria may first infect the skin, producing skin lesions. Once infected, dangerous substances called toxins, produced by the bacteria, can spread through your bloodstream to other organs, such as the heart, and cause significant damage. Because of widespread and routine childhood DPT immunizations, diphtheria is now rare in many parts of the world. There are fewer than five cases of diphtheria a year in the United States. Risk factors include crowded environments, poor hygiene, and lack of immunization. Symptoms Symptoms usually occur 2 to 5 days after you have come in contact with the bacteria.

Bluish coloration of the skin Bloody, watery drainage from nose Breathing problems
o o o

Difficulty breathing Rapid breathing Stridor

Chills

Croup-like (barking) cough Drooling (suggests airway blockage is about to occur) Fever Hoarseness Painful swallowing Skin lesions (usually seen in tropical areas) Sore throat (may range from mild to severe)

Note: There may be no symptoms. Signs and tests The health care provider will perform a physical exam and look inside your mouth. This may reveal a gray to black covering (pseudomembrane) in the throat, enlarged lymph glands, and swelling of the neck or larynx. Tests used may include:

Gram stain or throat culture to identify Corynebacterium diphtheriae Electrocardiogram (ECG)

Treatment If the health care provider thinks you have diphtheria, treatment should be started immediately, even before test results are available. Diphtheria antitoxin is given as a shot into a muscle or through an IV (intravenous line). The infection is then treated with antibiotics, such as penicillin and erythromycin. People with diphtheria may need to stay in the hospital while the antitoxin is being received. Other treatments may include:

Fluids by IV Oxygen Bed rest Heart monitoring Insertion of a breathing tube

Correction of airway blockages

Anyone who has come into contact with the infected person should receive an immunization or booster shots against diphtheria. Protective immunity lasts only 10 years from the time of vaccination, so it is important for adults to get a booster of tetanus-diphtheria (Td) vaccine every 10 years. Those without symptoms who carry diphtheria should be treated with antibiotics. Expectations (prognosis) Diphtheria may be mild or severe. Some people may not have symptoms. In others, the disease can slowly get worse. The death rate is 10%. Recovery from the illness is slow. Complications The most common complication is inflammation of the heart muscle (myocarditis). The nervous system is also frequently and severely affected, which may result in temporary paralysis. The diphtheria toxin can also damage the kidneys. Calling your health care provider Contact your health care provider if you have come in contact with a person who has diphtheria. Remember that diphtheria is a rare disease. Diphtheria is also a reportable disease, and any cases are often publicized in the newspaper or on television. This helps you to know if diphtheria is present in your area. Prevention Routine childhood immunizations and adult boosters prevent the disease. See: Diphtheria immunization (vaccine)

Botulism Botulism is a rare but serious illness caused by Clostridium botulinum bacteria. The bacteria may enter the body through wounds, or they may live in improperly canned or preserved food. Causes, incidence, and risk factors Clostridium botulinum is found in soil and untreated water throughout the world. It produces spores that survive in improperly preserved or canned food, where they produce toxin. When eaten, even tiny amounts of this toxin can lead to severe poisoning. The foods most commonly contaminated are home-canned vegetables, cured pork and ham, smoked or raw fish, and honey or corn syrup. Botulism may also occur if the bacteria enter open wounds and produce toxins there. Infant botulism occurs when a baby eats living bacteria or its spores and they grow in the baby's gastrointestinal tract. The most common cause of infant botulism is eating honey or corn syrup. Clostridium botulinum also occurs normally in the stool of some infants. About 110 cases of botulism occur in the U.S. per year. Most of the cases are in infants. Symptoms Symptoms usually appear 8 - 36 hours after you eat contaminated food. There is NO fever with this infection. In adults, symptoms may include:

Abdominal cramps Breathing difficulty that may lead to respiratory failure Difficulty swallowing and speaking Double vision

Dry mouth Nausea Vomiting Weakness with paralysis (equal on both sides of the body)

Symptoms in infants may include:

Constipation Poor feeding and weak sucking Respiratory distress Weak cry Weakness, loss of muscle tone

Signs and tests The health care provider will perform a physical exam. There may be signs of:

Absent or decreased deep tendon reflexes Absent or decreased gag reflex Eyelid drooping Loss of muscle function/feeling Paralyzed bowel Speech impairment Urine retention with inability to urinate

Blood tests can be done to identify the toxin. A stool culture may also be ordered. Lab tests can be done on the suspected food to confirm botulism. Treatment You will get botulinus antitoxin. For breathing trouble, you will have to stay in a hospital. The health care team will clear your airway and provide treatment. A tube may be inserted through the nose or mouth into the windpipe to provide an airway for oxygen. You may need a breathing machine.

Patients who have trouble swallowing may getintravenous fluids. A feeding tube may be inserted. Health care providers report cases of botulism to state health authorities or the U.S. Centers for Disease Control and Prevention so that the contaminated food can be removed from stores. Some people receive antibiotics, but they may not always help. Expectations (prognosis) Prompt treatment significantly reduces the risk of death.

Complications

Aspiration pneumonia and infection Long-lasting weakness Nervous system problems for up to 1 year Respiratory distress

Calling your health care provider Go to the emergency room or call the local emergency number (such as 911) if you suspect botulism. Prevention NEVER give honey or corn syrup to infants younger than 1 year old -- not even just a little taste on a pacifier. Prevent infant botulism by breastfeeding only, if possible. Always throw away bulging cans or foul-smelling preserved foods. Sterilizing home-canned foods by pressure cooking them at 250 degrees Fahrenheit for 30 minutes may reduce the risk for botulism. Keep foil-wrapped baked potatoes hot or in the refrigerator, not at room temperature.

Pertussis Whooping cough Pertussis is a highly contagious bacterial disease that causes uncontrollable, violent coughing. The coughing can make it hard to breathe. A deep "whooping" sound is often heard when the patient tries to take a breath. Causes, incidence, and risk factors Pertussis, or whooping cough, is an upper respiratory infection caused by the Bordetella pertussis or Bordetella parapertussis bacteria. It is a serious disease that can cause permanent disability in infants, and even death. When an infected person sneezes or coughs, tiny droplets containing the bacteria move through the air, and the disease is easily spread from person to person. The infection usually lasts 6 weeks. Whooping cough can affect people of any age. Before vaccines were widely available, the disease was most common in infants and young children. Now that most children are immunized before entering school, the higher percentage of cases is seen among adolescents and adults. Symptoms Initial symptoms, similar to the common cold, usually develop about a week after exposure to the bacteria. Severe episodes of coughing start about 10 to 12 days later. In children, the coughing often ends with a "whoop" noise. The sound is produced when the patient tries to take a breath. The whoop noise is rare in patients under 6 months of age and in adults.

Coughing spells may lead to vomiting or a short loss of consciousness. Pertussis should always be considered when vomiting occurs with coughing. In infants, choking spells are common. Other pertussis symptoms include:

Runny nose Slight fever (102 F or lower) Diarrhea

Signs and tests The initial diagnosis is usually based on the symptoms. However, when the symptoms are not obvious, pertussis may be difficult to diagnose. In very young infants, the symptoms may be caused by pneumonia instead. To know for sure, the health care provider may take a sample of mucus from the nasal secretions and send it to a lab, which tests it for pertussis. While this can offer an accurate diagnosis, the test takes some time, and treatment is usually started before the results are ready. Some patients may have a complete blood count that shows large numbers of lymphocytes. Treatment If started early enough, antibiotics such as erythromycin can make the symptoms go away more quickly. Unfortunately, most patients are diagnosed too late, when antibiotics aren't very effective. However, the medicines can help reduce the patient's ability to spread the disease to others. Infants younger than 18 months need constant supervision because their breathing may temporarily stop during coughing spells. Infants with severe cases should be hospitalized. An oxygen tent with high humidity may be used. Fluids may be given through a vein if coughing spells are severe enough to prevent the person from drinking enough fluids. Sedatives (medicines to make you sleepy) may be prescribed for young children.

Cough mixtures, expectorants, and suppressants are usually not helpful and should NOT be used. Expectations (prognosis) In older children, the outlook is generally very good. Infants have the highest risk of death, and need careful monitoring. Complications

Pneumonia Convulsions Seizure disorder (permanent) Nose bleeds Ear infections Brain damage from lack of oxygen Bleeding in the brain (cerebral hemorrhage) Mental retardation Slowed or stopped breathing (apnea) Death

Calling your health care provider Call your health care provider if you or your child develops symptoms of pertussis. Call 911 or get to an emergency room if the person has any of the following symptoms:

Bluish skin color, which indicates a lack of oxygen Periods of stopped breathing (apnea) Seizures or convulsions High fever Persistent vomiting Dehydration

Prevention DTaP vaccination, one of the recommended childhood immunizations, protects children against pertussis infection. DTaP vaccine can be safely given to infants. Five DTaP vaccines are recommended. They are usually given to children at ages 2 months, 4 months, 6 months, 15-18 months, and 4-6 years. The Tdap vaccine should be given around age 11 or 12, and every 10 years thereafter. During a pertussis outbreak, unimmunized children under age 7 should not attend school or public gatherings, and should be isolated from anyone known or suspected to be infected. This should last until 14 days after the last reported case. Many health care organizations strongly recommend that adults up to the age of 65 years receive the adult form of the vaccine against pertussis.

Botulism Botulism is a rare but serious illness caused by Clostridium botulinum bacteria. The bacteria may enter the body through wounds, or they may live in improperly canned or preserved food. Causes, incidence, and risk factors Clostridium botulinum is found in soil and untreated water throughout the world. It produces spores that survive in improperly preserved or canned food, where they produce toxin. When eaten, even tiny amounts of this toxin can lead to severe poisoning. The foods most commonly contaminated are home-canned vegetables, cured pork and ham, smoked or raw fish, and honey or corn syrup. Botulism may also occur if the bacteria enter open wounds and produce toxins there. Infant botulism occurs when a baby eats living bacteria or its spores and they grow in the baby's gastrointestinal tract. The most common cause of infant botulism is eating honey or corn syrup. Clostridium botulinum also occurs normally in the stool of some infants.

About 110 cases of botulism occur in the U.S. per year. Most of the cases are in infants. Symptoms Symptoms usually appear 8 - 36 hours after you eat contaminated food. There is NO fever with this infection. In adults, symptoms may include:

Abdominal cramps Breathing difficulty that may lead to respiratory failure Difficulty swallowing and speaking Double vision Dry mouth Nausea Vomiting Weakness with paralysis (equal on both sides of the body)

Symptoms in infants may include:

Constipation Poor feeding and weak sucking Respiratory distress Weak cry Weakness, loss of muscle tone

Signs and tests The health care provider will perform a physical exam. There may be signs of:

Absent or decreased deep tendon reflexes Absent or decreased gag reflex Eyelid drooping Loss of muscle function/feeling Paralyzed bowel

Speech impairment Urine retention with inability to urinate

Blood tests can be done to identify the toxin. A stool culture may also be ordered. Lab tests can be done on the suspected food to confirm botulism. Treatment You will get botulinus antitoxin. For breathing trouble, you will have to stay in a hospital. The health care team will clear your airway and provide treatment. A tube may be inserted through the nose or mouth into the windpipe to provide an airway for oxygen. You may need a breathing machine. Patients who have trouble swallowing may getintravenous fluids. A feeding tube may be inserted. Health care providers report cases of botulism to state health authorities or the U.S. Centers for Disease Control and Prevention so that the contaminated food can be removed from stores. Some people receive antibiotics, but they may not always help. Expectations (prognosis) Prompt treatment significantly reduces the risk of death.

Complications

Aspiration pneumonia and infection Long-lasting weakness Nervous system problems for up to 1 year Respiratory distress

Calling your health care provider Go to the emergency room or call the local emergency number (such as 911) if you suspect botulism. Prevention

NEVER give honey or corn syrup to infants younger than 1 year old -- not even just a little taste on a pacifier. Prevent infant botulism by breastfeeding only, if possible. Always throw away bulging cans or foul-smelling preserved foods. Sterilizing home-canned foods by pressure cooking them at 250 degrees Fahrenheit for 30 minutes may reduce the risk for botulism. Keep foil-wrapped baked potatoes hot or in the refrigerator, not at room temperature.

Tetanus Lockjaw Tetanus is infection of the nervous system with the potentially deadly bacteria Clostridium tetani (C. tetani). Causes, incidence, and risk factors Spores of the bacteria C. tetani live in the soil and are found around the world. In the spore form, C. tetani may remain inactive in the soil, but it can remain infectious for more than 40 years. Infection begins when the spores enter the body through an injury or wound. The spores release bacteria that spread and make a poison called tetanospasmin.

This poison blocks nerve signals from the spinal cord to the muscles, causing severe muscle spasms. The spasms can be so powerful that they tear the muscles or cause fractures of the spine. The time between infection and the first sign of symptoms is typically 7 to 21 days. Most cases of tetanus in the United States occur in those who have not been properly vaccinated against the disease. Symptoms Tetanus often begins with mild spasms in the jaw muscles (lockjaw). The spasms can also affect the chest, neck, back, and abdominal muscles. Back muscle spasms often cause arching, called opisthotonos. Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems. Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups. This is called tetany. These episodes can cause fractures and muscle tears. Other symptoms include:

Drooling Excessive sweating Fever Hand or foot spasms Irritability Swallowing difficulty Uncontrolled urination or defecation

Signs and tests Your doctor will perform a physical exam and ask questions about your medical history. No specific lab test is available to determine the diagnosis of tetanus. Other tests may be used to rule out meningitis, rabies, strychnine poisoning, and other diseases with similar symptoms. Treatment Treatment may include:

Antibiotics, including penicillin, clindamycin, erythromycin, or metronidazole (metronidazole has been most successful) Bedrest with a nonstimulating environment (dim light, reduced noise, and stable temperature) Medicine to reverse the poison (tetanus immune globulin) Muscle relaxers such as diazepam Sedatives Surgery to clean the wound and remove the source of the poison (debridement)

Breathing support with oxygen, a breathing tube, and a breathing machine may be necessary. Expectations (prognosis) Without treatment, one out of four infected people die. The death rate for newborns with untreated tetanus is even higher. With proper treatment, less than 10% of infected patients die. Wounds on the head or face seem to be more dangerous than those on other parts of the body. If the person survives the acute illness, recovery is generally complete. Uncorrected episodes of hypoxia (lack of oxygen) caused by muscle spasms in the throat may lead to irreversible brain damage. Complications

Airway obstruction Respiratory arrest Heart failure Pneumonia Fractures Brain damage due to lack of oxygen during spasms

Calling your health care provider Call your health care provider if you have an open wound, particularly if:

You are injured outdoors.

The wound has been in contact with soil. You have not received a tetanus booster (vaccine) within 5 years or you are not sure of your vaccination status.

Call for an appointment with your health care provider if you have never been immunized against tetanus as an adult or child, if your children have not been immunized, or if you are unsure of your tetanus immunization (vaccine) status. Prevention Tetanus is completely preventable by active tetanus immunization. Immunization is thought to provide protection for 10 years. Studies of soldiers suggest that good protection persists up to 12 years after the last immunization. In the United States, immunizations begin in infancy with the DTaP series of shots. The DTaP vaccine is a "3-in-1" vaccine that protects against diphtheria, pertussis, and tetanus. It is a safer version of an older vaccine known as DTP, which is no longer used in the U.S. Td vaccine or Tdap vaccine is used to maintain immunity in those age 11 and older. Tdap vaccine should be given once, prior to age 65, as a substitute for Td for those who have not had Tdap. Td boosters are recommended every 10 years starting at age 19. Older teenagers and adults who have sustained injuries, especially puncture-type wounds, should receive booster immunization for tetanus if more than 10 years have passed since the last booster. Thorough cleaning of all injuries and wounds and the removal of dead or severely injured tissue (debridement), when appropriate, may reduce the risk of developing tetanus. If you have been injured outside or in any way that makes contact with soil likely, contact your health care provider regarding the possible risk for tetanus. Many people believe injuries caused by rusty nails are the most dangerous. This is true only if the nail is dirty as well as rusty, as is usually the case. It is the dirt on the nail, not the rust, that carries the risk for tetanus. Gas gangrene Tissue infection - Clostridial; Gangrene - gas; Myonecrosis; Clostridial infection of tissues Gas gangrene is a potentially deadly form of tissue death (gangrene). See also: Necrotizing subcutaneous infection

Causes, incidence, and risk factors Gas gangrene is rare in the United States. The condition is most often caused by a bacteria called Clostridium perfringens. However, it also can be caused by Group A streptococcus. Staphylococcus aureus and Vibrio vulnificus can cause similar infections. Clostridium is found most everywhere. As the bacteria grow inside the body, it makes gas and harmful substances (toxins) that can damage body tissues, cells, and blood vessels. Gas gangrene develops suddenly. It usually occurs at the site of trauma or a recent surgical wound. About 1 in 5 cases occur without an irritating event. Patients most at risk for this usually have underlying blood vessel disease (atherosclerosis or hardening of the arteries), diabetes, or colon cancer. Symptoms Gas gangrene causes very painful swelling. The skin turns pale to brownish-red. If you press on the swollen area with your fingers, you may feel gas as a crackly sensation. The edges of the infected area grow so quickly that changes can be seen over a few minutes. The area may be completely destroyed. Symptoms include:

Air under the skin (subcutaneous emphysema) Blisters filled with brown-red fluid Drainage from the tissues, foul-smelling brown-red or bloody fluid (serosanguineous discharge) Increased heart rate (tachycardia) Moderate to high fever Moderate to severe pain around a skin injury Pale skin color, later becoming dusky and changing to dark red or purple Progressive swelling around a skin injury Sweating Vesicle formation, combining into large blisters Yellow color to the skin (jaundice)

Note: Symptoms usually begin suddenly and quickly worsen.

If the condition is not treated, the person can develop shock with decreased blood pressure (hypotension), kidney failure, coma, and finally death. Signs and tests The health care provider will perform a physical exam. This may reveal signs of shock. Tests that may be done include:

Tissue and fluid cultures to test for Clostridium bacteria Blood culture to determine the bacteria causing the infection Gram stain of fluid from the infected area X-ray, CT scan, or MRI of the area may show gas in the tissues.

Treatment Surgery is needed quickly to remove dead, damaged, and infected tissue. This is called debridement. Surgical removal (amputation) of an arm or leg may be needed to control the spread of infection. Amputation sometimes must be done before all test results are available. You will also be given antibiotics, usually penicillin-type and clindamycin. These medicines will be given through a vein (intravenously). Doctors have tried hyperbaric oxygen for this condition, with varying degrees of success. Pain medicines may also be prescribed. Expectations (prognosis) Gas gangrene usually begins suddenly and quickly gets worse. It is often deadly. Complications

Coma Delirium Disfiguring or disabling permanent tissue damage Jaundice with liver damage Kidney failure Shock

Spread of infection through the body (sepsis) Stupor

Calling your health care provider This is an emergency condition requiring immediate medical attention. Call your health care provider if you have signs of infection around a skin wound. Go to the emergency room or call the local emergency number (such as 911), if you have symptoms of gas gangrene. Prevention Clean any skin injury thoroughly. Watch for signs of infection (such as redness, pain, drainage, or swelling around a wound), and consult your health care provider promptly if these occur.

Anthrax Woolsorter's disease; Ragpicker's disease; Cutaneous anthrax; Gastrointestinal anthrax

Anthrax is an infectious disease due to a type of bacteria called Bacillus anthracis. Infection in humans most often involves the skin, gastrointestinal tract, or lungs. Causes, incidence, and risk factors Anthrax commonly affects hoofed animals such as sheep, cattle, and goats, but humans who come into contact with infected animals can get sick from anthrax, too. In the past, the people who were most at risk for anthrax included farm workers, veterinarians, and tannery and wool workers. There are three main routes of anthrax infection: Cutaneous anthrax occurs when anthrax spores touch a cut or scrape on the skin.

It is the most common type of anthrax infection. The main risk is contact with animal hides or hair, bone products, and wool, or with infected animals. People most at risk for cutaneous anthrax include farm workers, veterinarians, and tannery and wool workers.

Inhalation anthrax develops when anthrax spores enter the lungs through the respiratory tract. It is most commonly contracted when workers breathe in airborne anthrax spores during processes such as tanning hides and processing wool. Breathing in spores means a person has been exposed to anthrax, but it does not mean the person will have symptoms.

The bacteria spores must "germinate" or sprout (the same way a seed might sprout before a plant grows) before the actual disease occurs. The process usually takes 1 to 6 days. Forty-three days is the longest known incubation period. Once the spores germinate, they release several toxic substances. These substances cause internal bleeding, swelling, and tissue death.

Gastrointestinal anthrax occurs when someone eats anthrax-tainted meat. Anthrax may be used as a biological weapon or for bioterrorism. In 2001, anthrax sent through the U.S. Postal Service infected 22 people; 7 survivors had confirmed cutaneous anthrax disease.

Symptoms Symptoms of anthrax differ depending on the type of anthrax. Symptoms of cutaneous anthrax start 1 to 7 days after exposure:

An itchy sore develops that is similar to an insect bite. This sore may blister and form a black ulcer (sore). The sore is usually painless, but it is often surrounded by swelling. A scab often forms, and then dries and falls off within 2 weeks. Complete healing can take longer.

Symptoms of inhalation anthrax:

Begins with fever, malaise, headache, cough, shortness of breath, and chest pain Fever and shock may occur later

Symptoms of gastrointestinal anthrax usually occur within 1 week and may include:

Abdominal pain Bloody diarrhea Diarrhea Fever Mouth sores Nausea and vomiting (the vomit may contain blood)

Signs and tests The tests to diagnose anthrax depend on the type of disease that is suspected. A culture of the skin, and maybe a biopsy, are done on the skin sores. The sample is looked at under a microscope to identify the anthrax germ. Tests may include:

Blood culture Chest CT scan or chest x-ray

Spinal tap to check for infection around the spinal column (See:CSF culture) Sputum culture

Fluid or blood samples may be sent to a special laboratory for more testing, including PCR, immunofluorescence, and immunohistochemistry. Treatment Most people with anthrax are treated with antibiotics. Several antibiotics are effective, including penicillin, doxycycline, and ciprofloxacin. When treating inhalational anthrax, a combination of antibiotics should be used. Doctors often start treatment with ciprofloxacin plus another drug, given through a vein (intravenously). The length of treatment is about 60 days for people who have been exposed to anthrax, because it may take spores that long to germinate. Cutaneous (skin) anthrax is treated with antibiotics taken by mouth, usually for 7 to 10 days. Doxycycline and ciproflaxin are most often used. Expectations (prognosis) When treated with antibiotics, cutaneous anthrax is likely to get better. However, up to 20% of people who do not get treatment may die if anthrax spreads to the blood. People with second-stage inhalation anthrax have a poor outlook, even with antibiotic therapy. Up to 90% of cases in the second stage are fatal. Gastrointestinal anthrax infection can spread to the bloodstream, and may result in death. Calling your health care provider Call your health care provider if you have been exposed to anthrax, or if you develop symptoms of any type of anthrax. Prevention There are two main ways to prevent anthrax. For people who have been exposed to anthrax (but have no symptoms of the disease), doctors may prescribe preventive antibiotics, such as ciprofloxacin, penicillin, or doxycycline, depending on the strain of anthrax. An anthrax vaccine is available to military personnel and some members of the general public. It is given in a series of five doses over 18 months.

There is no known way to spread cutaneous anthrax from person to person. People who live with someone who has cutaneous anthrax do not need antibiotics unless they have also been exposed to the same source of anthrax.

Tularemia Deerfly fever; Rabbit fever; Pahvant Valley plague; Ohara disease; Yato-byo (Japan); Lemming fever Tularemia is an infection common in wild rodents that is passed to humans through contact with infected animal tissues or by ticks, biting flies, and mosquitoes. Causes, incidence, and risk factors Tularemia is caused by the bacterium Francisella tularensis. Humans can get the disease through:

A bite from an infected tick, horsefly, or mosquito Breathing in infected dirt or plant material Direct contact, through a break in the skin, with an infected animal or its dead body (most often a rabbit, muskrat, beaver, or squirrel) Eating infected meat (rare)

The disorder most commonly occurs in North America and parts of Europe and Asia. Although outbreaks can occur in the United States, they are rare. Some people may develop pneumonia after breathing in infected dirt or plant material. This is known to occur on Martha's Vineyard, where bacteria are present in rabbits, raccoons, and skunks. Francisella tularensis is considered a potential bioterrorism agent. An aerosol release would be a possible method of infection. Pneumonia cases would start 1 10 days after people were exposed. Symptoms The incubation period is 3 to 5 days after exposure. The illness usually starts suddenly, and may continue for several weeks after symptoms begin.

Chills Eye irritation ( conjunctivitis -- if the infection began in the eye)

Fever Headache Joint stiffness Muscle pains Red spot on the skin, growing to become a sore (ulcer) Shortness of breath Sweating Weight loss

Signs and tests

Blood culture for tularemia bacteria Blood test measuring the body's immune response to the infection (serology for tularemia) Chest x-ray Polymerase chain reaction (PCR) test of a sample from an ulcer

This disease may also affect the results of febrile agglutinins and some tests for infectious mononucleosis. Treatment The goal of treatment is to cure the infection with antibiotics. Streptomycin and tetracycline are commonly used to treat this infection. Once daily gentamicin treatment has been tried with excellent results as an alternative therapy to streptomycin. However, because this is a rare disease, only a few cases have been studied to-date. Tetracycline and chloramphenicol can be used alone, but they have a high relapse rate and are not considered a first-line treatment. Note: Oral tetracycline is usually not prescribed for children until after all their permanent teeth have come in. It can permanently discolor teeth that are still forming. Expectations (prognosis) Tularemia is fatal in about 5% of untreated cases, and in less than 1% of treated cases.

Complications

Bone infection (osteomyelitis) Infection of the sac around the heart (pericarditis) Meningitis Pneumonia

Calling your health care provider Call your health care provider if symptoms develop after a rodent bite, tick bite, or exposure to the flesh of a wild animal. Prevention A vaccine is recommended for people at high risk (trappers, hunters, and laboratory workers who work with the bacteria).

Brucellosis Rock fever; Cyprus fever; Undulant fever; Gibraltar fever; Malta fever; Mediterranean fever Brucellosis is an infectious disease that occurs from contact with animals carrying Brucella bacteria. Causes, incidence, and risk factors Brucella can infect cattle, goats, camels, dogs, and pigs. The bacteria can spread to humans if you come in contact with infected meat or the placenta of infected animals, or if you eat or drink unpasteurized milk or cheese. Brucellosis is rare in the United States. About 100 - 200 cases occur each year. People working in jobs where they often come in contact with animals or meat -such as slaughterhouse workers, farmers, and veterinarians -- are at higher risk. Symptoms Acute brucellosis may begin with mild flu-like symptoms, or symptoms such as:

Abdominal pain Back pain Chills Excessive sweating Fatigue Fever Headache Joint pain Loss of appetite Weakness Weight loss

High fever spikes usually occur every afternoon. The name "undulant" fever is because the fever rises and falls in waves.

Other symptoms that may occur with this disease:

Muscle pain Swollen glands

The illness may be chronic and last for years. Signs and tests

Blood culture Bone marrow culture Clean catch urine culture CSF culture Serology for brucellosis antigen

This disease may also change the results of the following tests:

Febrile/cold agglutinins Quantitative immunoglobulins (nephelometry) Serum immunoelectrophoresis

Treatment Antibiotics are used to treat the infection and prevent it from coming back. Longer courses of therapy may be needed if there are complications. Expectations (prognosis) Relapse may occur, and symptoms may continue for years. As with tuberculosis, the illness can come back after a long period of time. Complications

Bone and joint sores (lesions) Encephalitis Infective endocarditis Meningitis

Calling your health care provider Call for an appointment with your health care provider if:

You develop symptoms of brucellosis Your symptoms get worse or do not improve with treatment You develop new symptoms

Prevention Drinking and eating only pasteurized milk and cheeses is the most important way to prevent brucellosis. People who handle meat should wear protective glasses and clothing and protect skin breaks from infection. Detecting infected animals controls the infection at its source. Vaccination is available for cattle, but not humans.