Potential Bioterrorism Agents with Mucocutaneous Findings (Anthrax, Plague, Tularemia, Smallpox)

  • Mariana Martinez
  • Emily RoseEmail author


A bioterrorism attack may occur, and prompt recognition is essential to prevent morbidity and mortality induced by these agents. This chapter reviews the classic presentation, atypical presentation, disease time course, and diagnostic features of several conditions that could potentially be used in a bioterrorism attack. Anthrax, plague, tularemia, and smallpox are reviewed, and the evidence-based management of each condition is detailed for the provider.


Bioterrorism Biological warfare Anthrax Plague Tularemia Smallpox 


  1. 1.
    Sternbach G. The history of anthrax. J Emerg Med. 2003;24(4):463–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Bush LM, Perez MT. The Anthrax attacks 10 years later. Ann Intern Med. 2012;156:41–4.CrossRefPubMedGoogle Scholar
  3. 3.
    Brachman PS. Bioterrorism: an update with a focus on anthrax. Am J Epidemiol. 2002;155:981–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Inglesby TV, O’Toole T, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, et al. Anthrax as a biological weapon, 2002: updated recommendations for management. JAMA. 2002;287:2236–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Doganay M, Metan G, Alp E. A review of cutaneous anthrax and its outcome. J Infect Public Health. 2010;3:98–105.CrossRefPubMedGoogle Scholar
  6. 6.
    Cinquetti G, Banal F, Dupuy AL, et al. Three related cases of cutaneous anthrax in France: clinical and laboratory aspects. Medicine. 2009;88(6):371–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Carucci JA, McGovern TW, Norton SA, et al. Cutaneous anthrax management algorithm. J Am Acad Dermatol. 2002;47:766–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Adalja AA, Toner E, Inglesby TV. Clinical management of potential bioterrorism-related conditions. N Engl J Med. 2015;372:954–62.CrossRefPubMedGoogle Scholar
  9. 9.
    Swartz MN. Recognition and Management of Anthrax: an update. N Engl J Med. 2001;345(22):1621–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, Friedlander AM, et al. Anthrax as a biological weapon. JAMA. 1999;281:1735–45.CrossRefPubMedGoogle Scholar
  11. 11.
    Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adults. Emerging Infectious Diseases. 2014;20(2):e130687Google Scholar
  12. 12.
    Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl J Med. 1999;341:815–26.CrossRefPubMedGoogle Scholar
  13. 13.
    Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. 2000 May 3;283(17):2281–90.CrossRefPubMedGoogle Scholar
  14. 14.
    Prentice MB, Rahalison L. Plague. Lancet. 2007;369:1196.CrossRefPubMedGoogle Scholar
  15. 15.
    CDC. Prevention of plague: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1996;45(RR-14):1–15.Google Scholar
  16. 16.
    CDC. Human plague – four States, 2006. MMWR. 2006;55(34):940–3.Google Scholar
  17. 17.
    Aquino LI, Wu JJ. Cutaneous manifestation of category A bioweapons. J Am Acad Dermatol. 2011;65:1213.e1–15.CrossRefGoogle Scholar
  18. 18.
    Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Harrison’s principles of internal medicine, 19e; 2015 Available at: Accessed: 20 Nov 2017.
  19. 19.
    Kman NE, Nelson RN. Infectious agents of bioterrorism: a review for emergency physicians. Emerg Med Clin North Am. 2008;26(2):517–47.CrossRefPubMedGoogle Scholar
  20. 20.
    Hornick R. Tularemia revisited. N Engl J Med. 2001;345:1637–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public health management. JAMA. 2001;285:2763–73.CrossRefPubMedGoogle Scholar
  22. 22.
    Senel E, Satilmis O, Acar B. Dermatologic manifestations of tularemia: a study of cases in the mid-Anatolian region of Turkey. Int J Dermatol. 2015;54:e33–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Breman JG, Diagnosis HDA. Management of Smallpox. N Engl J Med. 2002;346(17):1300.CrossRefPubMedGoogle Scholar
  24. 24.
    Moore ZS, Seward JF, Lane JM. Smallpox. Lancet. 2006;367:425–35.CrossRefPubMedGoogle Scholar
  25. 25.
    Centers for Disease Control and Prevention. Smallpox: for clinicians. Accessed 10 Aug 2017.
  26. 26.
    Cunha BA. Anthrax, tularemia, plague, ebola or smallpox as agents of bioterrorism: recognition in the emergency room. Clin Microbiol Infect. 2002;8:489–503.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Emergency MedicineLos Angeles County + University of Southern California Medical CenterLos AngelesUSA
  2. 2.Department of Emergency MedicineKeck School of Medicine of the University of Southern California, Los Angeles County + USC Medical CenterLos AngelesUSA

Personalised recommendations