http://www.nytimes.com/2001/11/01/national/01DIAG.html
November 1, 2001
Disease Experts Struggle to Help Doctors Discern the Early Flu From Early
Anthrax
By LAWRENCE K. ALTMAN
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There is no definitive answer, in part because the initial symptoms of
influenza, anthrax and other infections can resemble one another. And yet it
may not be safe to wait for a confirmed diagnosis of inhalation anthrax before
a course of antibiotics is begun, because early antibiotics treatment appears
to be essential to saving anthrax patients' lives.
But experts in infectious diseases say a few clues may help distinguish the
early stages of influenza or some related illnesses from those of anthrax.
One important clue is that anthrax does not cause a stuffy nose like the
common cold or other respiratory ailments, said Dr. David Gilbert, president of
the Infectious Diseases Society of America.
In addition, at least one inhalation anthrax patient has reported a sore
throat as among his early symptoms, and a sore throat is not a common symptom
of influenza, Dr. Gilbert said. Some inhalation anthrax patients have also
experienced a feeling of heaviness in the chest.
Another clue is geography. Physicians should be on guard for anthrax in all
areas of the country, Dr. Gilbert said, but with anthrax cases so far limited
to Florida and the Middle Atlantic region, "you play the odds."
To help diagnose influenza, physicians should be encouraged to perform a
rapid test that detects an antigen, or protein, in the influenza virus.
"A doctor can do it in his or her office without the need for a fancy
laboratory," said Dr. Gilbert, who teaches at the Oregon Health Sciences
University and practices at Providence Portland Medical Center. Similar tests
exist for streptococcal infections of the throat.
Epidemiologists from the Centers for Disease Control and Prevention, here in
Atlanta, have said that doctors might have to err on the side of admitting some
patients to a hospital for antibiotic treatment, anthrax tests and observation.
Until more precise criteria are found, Dr. Gilbert said, "there will be
a lot of friction in the system from unnecessary doctor visits, I am
afraid."
For the broad population to pay careful attention to early symptoms may have
taken on even greater importance with Kathy T. Nguyen's death of inhalation
anthrax in New York City today, less than a week after she experienced her
first, mild symptoms. Ms. Nguyen, 61, became ill at a time when federal health
officials had begun urging doctors to pay special attention to postal workers
who complained of mild, vague symptoms, because those symptoms might develop
into a flulike illness that has often preceded the more severe symptoms of
anthrax.
But Ms. Nguyen did not work in a post office or at a news organization,
another broad category of workplace made a target of anthrax attacks. And it is
not known what mail she might have handled at her job at the Manhattan Eye, Ear
and Throat Hospital, or at home in the Bronx. So her death appears to broaden
the population that must be concerned about vague flulike symptoms.
One point of confusion is that people use "the flu" as a medically
nonspecific term to describe a wide variety of ailments with both intestinal
and respiratory symptoms. And patients who have contracted inhalation anthrax
in the current outbreak have described their early symptoms as respiratory or
intestinal flu.
Standard measures like checking a temperature may not be diagnostic, because
both influenza and anthrax can cause fever. Both conditions can also cause
muscle aches.
But chest X-rays can help doctors diagnose inhaled anthrax. The anthrax
bacilli are carried by scavenger cells to the lymph nodes behind the lungs and
in front of the spine. The bacilli cause the nodes to enlarge, producing a
characteristic swelling that can be detected on chest X-rays. Officials of the
Centers for Disease Control and Prevention have urged doctors to look for the
finding, known as a widened mediastinum, if a need for X-rays is indicated.
While influenza is caused by a virus, it can lead to a secondary infection,
pneumonia, caused by bacteria. But pneumonia has not been considered a part of
inhalation anthrax.
In its later stages, anthrax can cause severe respiratory distress because
fluid accumulates in the pleural covering of the lungs and compresses them. The
fluid can sometimes be bloody.
For now, at least, no one at the disease control centers is suggesting that
early diagnosis will be easy.
"Those first few hours, the first time" a doctor sees a patient,
"are difficult," said Dr. Jeffrey Koplan, the director of the
centers. "No one is going to walk in and say, `Oh, this must be anthrax,'
when someone comes in with a cough and a cold and a headache."
Dr. Koplan said scientists at his agency were working with practicing
physicians to come up with better diagnostic techniques that might be available
when the flu season begins in a few weeks.
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