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Discriminating Inhalational Anthrax From Community-Acquired Pneumonia Using Chest Radiograph Findings and a Clinical Algorithm^*

^* From the Department of Emergency Medicine (Drs. Kyriacou and Yarnold, Mr. Stein, and Ms. Nelson), the Divisions of Infectious Diseases (Dr. Noskin) and General Internal Medicine (Dr. Belknap), and the Center for Healthcare Studies (Dr. Bennett), Northwestern University Feinberg School of Medicine, Chicago, IL; the Department of Medicine (Dr. Schmitt), Loyola University Medical Center, Maywood, IL; the Jesse Brown VA Medical Center (Mr. Soltysik), Chicago, IL; and the Department of Epidemiology (Dr. Frerichs), UCLA School of Public Health, Los Angeles, CA.

Correspondence to: Demetrios N. Kyriacou, MD, PhD, Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, 259 Erie St, Suite 100, Chicago, IL 60611; e-mail: dkyriacou{at}aol.com

Abstract

Background: Limiting the effects of a large-scale bioterrorist anthrax attack will require rapid and accurate detection of the earliest victims. We undertook this study to improve physicians’ ability to rapidly detect inhalational anthrax victims.

Methods: We conducted a case-control study to compare chest radiograph findings from 47 patients from historical inhalational anthrax cases and 188 community-acquired pneumonia control subjects. We then used classification tree analyses to derive an algorithm of chest radiograph findings and clinical characteristics that accurately and explicitly discriminated between inhalational anthrax and community-acquired pneumonia.

Results: Twenty-two of the 47 patients from historical inhalational anthrax cases (46.8%) had reported chest radiograph findings. All 22 case patients (100%) had mediastinal widening, pleural effusion, or both. However, 16 case patients (72.7%) also had infiltrates. In comparison, all 188 community-acquired control subjects had reported chest radiographs. Of these, 127 control subjects (67.6%) had infiltrates, 43 control subjects (22.9%) had pleural effusions, and 15 control subjects (8.0%) had mediastinal widening. A derived algorithm with three predictor variables (chest radiograph finding of mediastinal widening, altered mental status, and elevated hematocrit) is 100% sensitive (95% confidence interval [CI], 73.5 to 100) and 98.3% specific (95% CI, 95.1 to 99.6). The derivation process used 12 patients with inhalational anthrax and 177 control subjects with community-acquired pneumonia who had information available for all three variables.

Conclusions: There are significant chest radiograph differences between inhalational anthrax and community-acquired pneumonia, but none of the chest radiograph findings are both highly sensitive and highly specific. The derived clinical algorithm can improve physicians’ ability to discriminate inhalational anthrax from community-acquired pneumonia, but its utility is limited to previously healthy individuals and its accuracy may be limited by missing values.

Key Words: algorithm • anthrax • bioterrorist attack