Outbreaks Open Access
Like 0


On 31 August, a veterinarian and a farmworker were hospitalised for skin lesions. Both had been exposed to a dead cow on 19 August on a farm near Rome, where eight further cattle died of confirmed anthrax later the same month. At admission, the first case showed a black depressed eschar and another smaller lesion on one hand. The second case presented deep infection of the skin, with involvement of both arms. Anthrax diagnosis was confirmed by detection of DNA in eschar fragments from both patients. T-cell specific immunity was studied by flow cytometry and Elispot assay after stimulation with secretome in blood samples collected from Case 1. Immunoglobulin production was detected by complement fixation assay. In Case 1, specific CD4+ T-cell activation was detected, without antibody production. Specific antibodies were detected only in the second patient with severe cutaneous illness. Both patients recovered. The two human anthrax cases were epidemiologically linked, but anthrax was not suspected at admission in either case. The veterinarian had initially unrecognised professional exposure and the exposed farmworker did initially not report exposure to affected animals. A One Health strategy integrating human and animal investigations was essential to confirm the diagnosis.


Article metrics loading...

Loading full text...

Full text loading...



  1. Doganay M, Demiraslan H. Human anthrax as a re-emerging disease. Recent Pat Antiinfect Drug Discov. 2015;10(1):10-29.  https://doi.org/10.2174/1574891X10666150408162354  PMID: 25851429 
  2. Fasanella A, Garofolo G, Galante D, Quaranta V, Palazzo L, Lista F, et al. Severe anthrax outbreaks in Italy in 2004: considerations on factors involved in the spread of infection. New Microbiol. 2010;33(1):83-6. PMID: 20402418 
  3. Palazzo L, De Carlo E, Santagada G, Serrecchia L, Aceti A, Guarino A, et al. (Study and management of the 2011 anthrax outbreaks in Basilicata and Campania. Considerations on potential factors that favor an epidemic-like evolution of the disease). Studio e gestione dei focolai di carbonchio ematico del 2011 in Basilicata e in campania.Considerazioni sui potenziali fattori che favoriscono una evoluzione simil-epidemica della malattia. Large Anim Rev. 2012;(3):107-11.
  4. Rombolà P. (OEVR Lazio, IZSLT) [Geographical localization of outbreaks of anthrax reported in the province of Rome since 1952. Interactive thematic map]. Rome: IZSLT; 2018. Italian. Available from: http://www.izslt.it/agentizoonosicispeciali/carbonchio-ematico-antrace/
  5. Fasanella A, Garofolo G, Galella M, Troiano P, De Stefano C, Pace L, et al. Suspect vector transmission of human cutaneous anthrax during an animal outbreak in Southern Italy. Vector Borne Zoonotic Dis. 2013;13(10):769-71.  https://doi.org/10.1089/vbz.2013.1302  PMID: 23808978 
  6. Fasanella A, Palazzo L, Petrella A, Quaranta V, Romanelli B, Garofolo G. Anthrax in red deer (Cervus elaphus), Italy. Emerg Infect Dis. 2007;13(7):1118-9.  https://doi.org/10.3201/eid1307.061465  PMID: 18214198 
  7. Battisti A. ProMED-mail. Anthrax - Italy (02): (Lazio) Comment Archive Number: 20170901.5289951. 1 Sep 2017. Available from: http://www.promedmail.org/post/20170901.5289951
  8. International Organization for Animal Health (OIE). Anthrax. In: Manual of diagnostic tests and vaccines for terrestrial animals. Paris: OIE; 2018. Available from: http://www.oie.int/fileadmin/Home/eng/Health_standards/tahm/2.01.01_ANTHRAX.pdf
  9. Ramisse V, Patra G, Garrigue H, Guesdon JL, Mock M. Identification and characterization of Bacillus anthracis by multiplex PCR analysis of sequences on plasmids pXO1 and pXO2 and chromosomal DNA. FEMS Microbiol Lett. 1996;145(1):9-16.  https://doi.org/10.1111/j.1574-6968.1996.tb08548.x  PMID: 8931320 
  10. Van Ert MN, Easterday WR, Huynh LY, Okinaka RT, Hugh-Jones ME, Ravel J, et al. Global genetic population structure of Bacillus anthracis. PLoS One. 2007;2(5):e461.  https://doi.org/10.1371/journal.pone.0000461  PMID: 17520020 
  11. Yamada S, Ohashi E, Agata N, Venkateswaran K. Cloning and nucleotide sequence analysis of gyrB of Bacillus cereus, B. thuringiensis, B. mycoides, and B. anthracis and their application to the detection of B. cereus in rice. Appl Environ Microbiol. 1999;65(4):1483-90. PMID: 10103241 
  12. Adone R, Sali M, Francia M, Iatarola M, Donatiello A, Fasanella A. Development of a Sterne-based complement fixation test to monitor the humoral response induced by anthrax vaccines. Front Microbiol. 2016;7:19.  https://doi.org/10.3389/fmicb.2016.00019  PMID: 26858700 
  13. Borrello S. Immediate notification: Rocca di Papa, ROMA, Lazio. World Animal Health (OIE) Information Database (WAHID) Interface. Paris: OIE; 2017. Available from: http://www.oie.int/wahis_2/public/wahid.php/Reviewreport/Review?page_refer=MapFullEventReport&reportid=24702
  14. Borrello S. Anthrax - Italy: (Lazio) Bovine. OIE, WAHID (World Animal Health Information Database), weekly disease information. 2018;31(12). Available from: http://www.oie.int/wahis_2/public/wahid.php/Reviewreport/Review?page_refer=MapFullEventReport&reportid=26195
  15. Turner WC, Imologhome P, Havarua Z, Kaaya GP, Mfune JKE, Mpofu IDT, et al. Soil ingestion, nutrition and the seasonality of anthrax in herbivores of Etosha National Park. Ecosphere. 2013;4(1):13.
  16. Battisti A, Panfili G, Di Guardo G, Aleandri M. Carbonchio ematico negli animali domestici. La malattia in provincia di Roma dal 1952 al 1992. [Anthrax in domestic animals. The disease in the province of Rome from 1952 to 1992]. Rome: Istituto Zooprofilattico Sperimentale delle Regioni Lazio e Toscana. [Accessed: 7 Oct 2015] Italian. Available from: http://www.epicentro.iss.it/problemi/antrace/pdf/Carbonchio.pdf
  17. Quinn CP, Dull PM, Semenova V, Li H, Crotty S, Taylor TH, et al. Immune responses to Bacillus anthracis protective antigen in patients with bioterrorism-related cutaneous or inhalation anthrax. J Infect Dis. 2004;190(7):1228-36.  https://doi.org/10.1086/423937  PMID: 15346332 
  18. Laughlin EM, Miller JD, James E, Fillos D, Ibegbu CC, Mittler RS, et al. Antigen-specific CD4+ T cells recognize epitopes of protective antigen following vaccination with an anthrax vaccine. Infect Immun. 2007;75(4):1852-60.  https://doi.org/10.1128/IAI.01814-06  PMID: 17283103 
  19. Ingram RJ, Metan G, Maillere B, Doganay M, Ozkul Y, Kim LU, et al. Natural exposure to cutaneous anthrax gives long-lasting T cell immunity encompassing infection-specific epitopes. J Immunol. 2010;184(7):3814-21.  https://doi.org/10.4049/jimmunol.0901581  PMID: 20208010 
  20. Ascough S, Ingram RJ, Chu KK, Musson JA, Moore SJ, Gallagher T, et al. CD4+ T cells targeting dominant and cryptic epitopes from Bacillus anthracis lethal factor. Front Microbiol. 2016;6:1506.  https://doi.org/10.3389/fmicb.2015.01506  PMID: 26779161 
  21. Kwok WW, Yang J, James E, Bui J, Huston L, Wiesen AR, et al. The anthrax vaccine adsorbed vaccine generates protective antigen (PA)-Specific CD4+ T cells with a phenotype distinct from that of naive PA T cells. Infect Immun. 2008;76(10):4538-45.  https://doi.org/10.1128/IAI.00324-08  PMID: 18678674 
  22. Ingram RJ, Ascough S, Reynolds CJ, Metan G, Doganay M, Baillie L, et al. Natural cutaneous anthrax infection, but not vaccination, induces a CD4(+) T cell response involving diverse cytokines. Cell Biosci. 2015;5(1):20.  https://doi.org/10.1186/s13578-015-0011-4  PMID: 26075052 

Data & Media loading...

Supplementary data

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error