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Lymphocytic vasculitis associated with the anthrax vaccine: case report and review of anthrax vaccination
The Journal of Emergency Medicine, Vol. 25, No. 3, pp. 271–276, 2003 Copyright © 2003 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/03 $–see front matter
doi:10.1016/S0736-4679(03)00201-4
Clinical Communications
LYMPHOCYTIC VASCULITIS ASSOCIATED WITH THE ANTHRAX VACCINE: CASE REPORT AND REVIEW OF ANTHRAX VACCINATION Antonio E. Mun˜iz,
MD, FACEP, FAAP
Department of Emergency Medicine and Pediatrics, Medical College of Virginia, Richmond, Virginia Reprint Address: Antonio E. Mun˜iz, MD, FACEP, FAAP, Department of Emergency Medicine and Pediatrics, Medical College of Virginia, 401 N. 12th Street, Richmond, VA 23298-0401
e Abstract—Anthrax is caused by the spore-forming bacteria Bacillus anthracis. It occurs naturally, but recently has been manufactured as a biological warfare agent. This makes prophylaxis for anthrax an urgent concern and efforts are ongoing for the production of an efficient and safe vaccine. Side effects to the current anthrax vaccine are usually minor and mainly consist of local skin reactions. Occasionally an unusual complication may occur; a case of a patient with lymphocytic vasculitis temporally associated with the anthrax vaccine is reported. © 2003 Elsevier Inc.
to the current anthrax vaccine are usually minor and mainly consist of local skin reactions (5,6). Occasionally, an unusual complication may occur, and in this article a patient with lymphocytic vasculitis temporally associated with the anthrax vaccine is reported.
CASE REPORT A previously healthy 53-year-old male Air Force Reserve Officer presented to our Emergency Department (ED) with a painful rash localized to the lower extremities. He reported receiving his fourth anthrax vaccination (BioPort Corporation, Lansing, MI) 11 days prior. Six days after receiving his anthrax vaccine he developed a low-grade fever, chills, and an erythematous rash on his feet and legs. Over the next few days, the rash became more erythematous and edema developed. He denied pruritus or arthralgias. He had no significant medical illnesses, took acetaminophen for pain and had no allergies. He denied any recent bacterial infections, tattoos, blood transfusions, chemical exposures, or any foreign travel, including being deployed to the Persian Gulf War. His initial vital signs were a blood pressure 115/71 mm Hg, heart rate 82 beats/min, respiratory rate 16 breaths/min, and temperature 38.1°C. Physical examination revealed a middle-aged man in mild discomfort from
e Keywords—lymphocytic vasculitis; anthrax vaccine
INTRODUCTION Anthrax is caused by the spore-forming bacteria Bacillus anthracis. In addition to causing naturally occurring anthrax, it has been manufactured as a biological warfare agent, a recent reality in the United States (1,2). Anthrax has been a focus of offensive and defensive biological warfare research programs for over 60 years (3). Development of new strains resistant to antibiotics or containing more powerful virulence factors could be the next batch of terrorist attacks, which could render our current antibiotic recommendations for prophylaxis and treatment powerless (4). This makes prophylaxis for anthrax an urgent concern and efforts are ongoing for the production of an efficient and safe vaccine (3,4). Side effects
RECEIVED: 21 June 2002; FINAL ACCEPTED: 5 March 2003
SUBMISSION RECEIVED:
29 January 2003; 271
272
A. E. Mun˜ iz
Figure 1. Patient’s lower extremity showing petechiae, purpura, scattered red macules, and edema.
pain. He had no lymphadenopathy. His lung and heart examinations were normal. He had no hepatosplenomegaly. His entire lower extremities had 3⫹ pitting edema. Both lower extremities had numerous petechiae, greater than 100, which became confluent as purpura in the lower part of the lower extremities (Figure 1). On the thigh there were scattered red macules, which blanched upon diskoscopy. Dermatology was consulted and a 4 mm punch biopsy was obtained. The white blood cell (WBC) count was 4900/mm3 with 71% neutrophils. The hemoglobin was 14.1 g/dL and platelets 193,000/mm3. Electrolytes, BUN, and creatinine were normal. The prothrombin time (PT) and activated partial prothrombin time (aPTT) were normal. The patient was discharged and returned to Dermatology clinic in 1 week to review the results of other laboratory tests. Rheumatoid factor was ⬍8 IU/mL, hepatitis A, B, and C panels were negative, Westergren sedimentation rate 25 mm/h, and the antinuclear antibody (ANA) was negative. The surgical histopathologic specimen showed superficial and mid-reticular dermal infiltrates, primarily lymphocytes. Local infiltration of lymphocytes within the walls of blood vessels was evident and extravasation of red blood cells was prominent. There was focal deposition of fibrin within the blood vessels and edema within the papillary dermis. Immunofluorescence studies showed vascular deposition of C3
and fibrin within the vessel walls. There was no IgA, IgM, C4, or C1q deposited. The histopathological and clinical impression was a lymphocytic vasculitis. He was reevaluated in the Dermatology clinic and symptoms resolved in 6 months.
DISCUSSION Anthrax is a zoonotic infection. Bacillus anthracis is a large, aerobic, Gram-positive bacterium whose endospores are found in the soil. Its high resistance to destruction makes it an ideal agent for a biological weapon. Human infection can result from abraded skin contact with either contaminated animals or animal products, or by inhalation or ingestion of endospores (7). Human anthrax occurs in three main forms: inhalational, cutaneous, and gastrointestinal. Recently, in the United States, cutaneous and inhalational anthrax have occurred from envelopes deliberately inoculated with anthrax spores. Unfortunately, inhalational anthrax presents with nonspecific symptoms that may not be easily distinguished from many more common diseases, especially influenza virus infections. In most cases, anthrax is usually not diagnosed until more recognizable symptoms occur, and by then the patient may die, despite appropriate antimicrobial therapy (1,2). Since the occurrence of recent anthrax cases, prevention of anthrax through a vaccina-
Anthrax Vaccine
tion program has become high priority in the United States. Bacillus anthracis possesses three known virulence factors, an antiphagocytic capsule and 2 protein exotoxins, lethal toxin, and edema toxin. The major virulence factors of B. anthracis are encoded on two virulence plasmids, pXO1 and pXO2, that carry the genes encoding various virulence factors. The toxin-bearing plasmid, pXO1, encodes for the genes that make up the secreted exotoxins. The toxin-gene complex is composed of protective antigen, lethal factor, and edema factor. The three exotoxin components combine to form two binary toxins, edema toxin and lethal toxin. Both plasmids are required for full virulence and the loss of either one results in an attenuated strain. In the past, bacterial strains used in the formulation of the anthrax vaccine were made by rendering virulent strains free of one or both plasmids. The Pasteur strain is the avirulent pXO2-carrying strain that is encapsulated but does not express exotoxin components (7). The Sterne strain is an attenuated strain that carries pXO1 and can synthesize exotoxin components but does not have a capsule (7). To date, the only known effective prevention against anthrax is through the administration of the anthrax vaccine. Because the incidence of all forms of naturally occurring anthrax, and most importantly the inhalational form, is exceedingly low, there is no opportunity to conduct new human trials for the effectiveness of vaccines against clinical anthrax. Furthermore, the high mortality rate associated with inhalational anthrax would ethically preclude any human challenge studies. Thus, we are left with the conundrum of how these previous field trials and experimental animal models translate to humans. The first vaccines that were administered to animals showed that inoculation of animals with attenuated strains of B. anthracis led to adequate protection from exposure to anthrax (8,9). Experimentation with filtrates of artificially or in vitro cultivated B. anthracis led to the formulation of the vaccine that is currently administered today (10 –12). The first nonlive vaccine, developed in 1954, was an aluminum potassium sulfate (alum)-precipitated cell-free filtrate from a B. anthracis aerobic culture (13). In the next few years the vaccine was improved by both using a strain of B. anthracis that produced a higher fraction of protective antigen and use of aluminum hydroxide as the adjuvant (11,12). This vaccine is believed to stimulate humoral but not cell-mediated immunity (14). This is the only licensed anthrax vaccine in the United States and is termed Anthrax Vaccine Adsorbed (or AVA). It is an aluminum hydroxide-precipitated preparation (BioPort Corporation) of protective antigen from attenuated, nonencapsulated B. anthracis cultures of the Sterne strain known as V770-NP1-R (11,15–17).
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The filtrate contains a mixture of cellular products, including all three components, lethal factor, edema factor, and protective antigen, and is adsorbed to aluminum hydroxide (Amphogel, Wyeth Laboratories, Madison, NJ) as adjuvant (16,18). The efficacy of AVA is based on several animal studies and immunogenicity data for both humans and animals. There are no prospective, randomized, placebocontrolled human clinical studies using AVA. In rhesus monkeys, inoculations with AVA afforded substantial protection against inhalational anthrax (13,19,20). There are very limited trials in humans that show a similar protection against cutaneous anthrax (5). The standard vaccine in the United States was approved by the Food and Drug Administration in 1970 and is routinely administered to people at risk for exposure to anthrax spores. People at risk include individuals who may come in contact with animal products at risk to be contaminated with Bacillus anthracis spores, individuals engaged in diagnostic or investigational activities that may bring them in contact with B. anthracis spores, and persons at high risk, such as veterinarians and others handling potentially infected animals. However, the vaccine has not been manufactured since February of 1998. Due to the current world threat of biological warfare, Secretary of Defense William S. Cohen made it mandatory to vaccinate the United States Armed Forces. Thus, all the remaining supplies of the vaccine are currently being given to immunize all military personnel and are not available for civilian use. It is the goal of the military to have all 2.4 million Active, Guard, and Reserve service members inoculated by 2003 (4). AVA is administered subcutaneously in a series of 0.5-ml doses at 0, 2, and 4 weeks, then at 6, 12, and 18 months (19,21). Thereafter, annual booster doses are administered. Adverse effects of the vaccine were first encountered during the prelicensure evaluation of 6,985 people who received 16,435 doses (22). Mild local reactions occurred in 3–20% of vaccinations, moderate reactions occurred in 1–3%, whereas only 1% had severe local reactions. Most of the reactions included erythema, tenderness, and edema commonly at the site of inoculation. Systemic reactions, such as malaise, fever, chills, body aches, nausea, headache, and myalgia occurred in ⬍0.06% (22,23). Since March 10, 1998, the active Anthrax Vaccine Immunization Program has given AVA to military personnel. To monitor the incidence of adverse reactions from vaccines, the Food and Drug Administration and Centers for Disease Control and Prevention jointly developed the Vaccine Adverse Event Reporting System (VAERS) in 1990 (6). The Department of Defense policy encourages health care providers to report all adverse events possibly associated with AVA vaccination and
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specifically requires all adverse events resulting in loss of duty more than 24 h or hospitalization to be reported. Reporting to the VAERS can be performed by a health care provider, patient, or anyone else. The report of an adverse event to VAERS is not confirmation that the vaccine caused the event, only that the event occurred in a temporal relationship with the vaccine administration. Because it is difficult to distinguish a coincidental from a causative event, the VAERS database, a passive surveillance system, contains all reports. From January 1, 1990 through November 29, 2001 there have been 2,098,544 doses of anthrax vaccines with 1,685 reports of adverse events (24). Serious events are defined as death, life threatening, hospitalization, or any permanent disability. Of the reported adverse events, there were 76 (5%) serious events. The most frequently reported adverse events were injection-site hypersensitivity, injection-site edema or pain, headache, arthralgia, asthenia, and pruritus. Anaphylaxis has occurred only in 2 patients. Likewise, death has been reported in 2 patients; one had an autopsy with a final diagnosis of coronary arteritis and the second had aplastic anemia. The cause of these deaths has not been definitely linked to anthrax vaccine. Other serious events have included cellulitis, Guillain-Barre´ syndrome, pneumonia, seizures, cardiomyopathy, multiple sclerosis, collagen vascular disease, systemic lupus erythematosus, sepsis, angioedema, and tranverse myelitis (3). Formal analysis of VAERS data demonstrates no pattern of serious adverse events clearly associated with the vaccine, except that of primary local injection-site reactions. The limitation of the VAERS data is that it is a self-reporting system and it is often very difficult to determine the exact etiology of the reported event. For a variety of reasons, vaccine-related adverse events may not have been reported to VAERS. Some members of the armed forces, especially those in the reserves, are likely to seek medical attention from their personal physicians. In addition, the possibility that a relationship exists between the symptoms and the anthrax vaccine may not be apparent to either the patient or the physician. Other pressures may also hinder reporting, such that reporting these events may make them not suitable for full active duty, and thereby may negatively influence their military careers. The Institute of Medicine, in an assessment of a few short-term studies, reported no significant adverse effects after the anthrax vaccination (25). A 25-year surveillance of anthrax vaccine at Fort Detrick did not reveal any unusual illnesses or unexplained symptoms (26,27). A delayed anaphylactoid reaction and delayed-type hypersensitivity reaction temporally related to an anthrax vaccination have been reported (28,29). There have been no reports of the occurrence of chronic diseases associated with the anthrax vaccine.
A. E. Mun˜ iz
In the case reported, there was a close relationship between the anthrax vaccination and the development of lymphocytic vasculitis. Cutaneous lymphocytic vasculitis is a clinicopathological process characterized by lymphocytic inflammation of, and damage to, dermal blood vessels. It is accompanied by fibrin deposition in the blood vessel walls or lumens, or both (30). The syndrome is presumed to be associated with an aberrant hypersensitivity reaction to an antigen such as an infectious agent, drug, or other foreign or endogenous substance. There have been multiple mechanisms implicated, such as circulating antigen-antibody complexes, type IV delayed hypersensitivity reactions, and cell-mediated or endothelial attack by lymphocytes (31–34). Elevations of serum immunoglobulin levels are relatively common with lymphocytic vasculitis (35). IgA and IgM are more commonly elevated than IgG (35,36). Immunofluorescent studies have shown vascular deposits of IgG or C3 (35,36). These findings also have been seen in erythema multiforme, pigmentary purpura, and pityriasis lichenoides et varioliformis acuta (37). In the patient reported here it is unclear whether the vasculitis was due to an altered immune system response to the antigens in the vaccine or to the presence of either the preservative or adjuvant agents. AVA contains benzethonium chloride as a preservative and formaldehyde as a stabilizer. There is limited information about the effects that these preservatives or adjuvant agents may have on humans. Review of the current medical literature [Medline from 1966] shows no reports of vasculitis caused from any of these agents. Formaldehyde is a known sensitizer, responsible for asthmatic reactions, ocular and dermal irritation (38 – 40). Benzethonium chloride, often found in topical medications, has been implicated in a limited number of cases of contact dermatitis (41,42). Aluminum hydroxide has been shown to be a weak skin irritant and has caused granuloma years after an injection of adsorbed diphtheria, tetanus, and pertussis (DTP) vaccine (43– 46). Others have reported pruritus, dermatitis, hyperpigmentation, or hypertrichosis (47). Therefore, it seems that the vasculitis is more likely a result of an abnormal immunologic response to the bacterial antigen than to the vaccine excipients. Problems with the AVA such as complex dosing schedule, and high incidence of local reactions has prompted newer vaccines to be tested that may be easier and more practical to administer. The newer vaccines should ideally generate both cell-mediated as well as humoral immunity, and inhibit spore germination. These newer vaccines may include preparations of protective antigen subunits with different adjuvants, protective antigen purified from recombinant sources, and live vaccines based on anthrax strains with auxotrophic mutations (48 –54). The ability of any of these new vaccines
Anthrax Vaccine
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to protect humans in the event of a widespread aerosol attack of biological warfare is not known (55). With advances in biotechnology and allegations that recombinant strains of anthrax with greater virulence factors than the native strains are likely to be formulated, it is possible that the current generation of vaccine will not be protective. Furthermore, it may take years to develop, license, manufacture, administer, and confer immunity using newly formulated vaccines. Even if the anthrax vaccine is found to be highly effective against a potential biological warfare, other factors may preclude its widespread implementation. Many military personnel have recently refused to take the anthrax vaccination, despite being the most likely population to initially encounter the threat. In addition, many parents refuse to administer to their children approved vaccinations against common diseases for fear of their rare complications. Although there is probably a role for the anthrax vaccine, it should not be expected to provide a robust biological defense.
CONCLUSIONS The threat of biological warfare by means of inhalational anthrax is an unfortunate reality. The risk assumed from the employment of a large-scale anthrax vaccination program must be weighed against the risk of no prevention, namely, a mass number of fatalities incurred from exposure to inhalational anthrax. The major advantage of a vaccination program is the potential prevention of fatalities from what is generally accepted as a lethal exposure versus the transient, predominantly local adverse vaccine reactions. Although a rare, previously unknown adverse effect, such as lymphocytic vasculitis, may occur, there is no scientific evidence to date that such problems have been reported in any significant amounts in nearly 30 years experience with the use of AVA.
REFERENCES 1. Mina B, Dym JP, Kuepper F, et al. Fatal inhalational Anthrax with unknown source of exposure in a 61-year-old woman in New York City. JAMA 2002;287:858 – 62. 2. Barakat LA, Quentzel HL, Jernigan JA, et al. Fatal inhalational anthrax in a 94-year-old Connecticut woman. JAMA 2002;287: 863– 8. 3. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices. J Toxicol Clin Toxicol 2001;39:85–100. 4. Nass M. Anthrax vaccine. Model of a response to the biological warfare threat. Infect Dis Clin North Am 1999;13:187–208. 5. Brachman PS, Gold H, Plotkin SA, Fekety FR, Werrin M, Ingraham NR. Field evaluation of a human anthrax vaccine. Am J Public Health 1962;52:632– 42.
6. Chen RT, Rastogi SC, Mullen JR, et al. The Vaccine Adverse Events Reporting System (VAERS). Vaccine 1994;12:542–50. 7. Hanna P. Anthrax pathogenesis and host response. Curr Top Microbiol Immunol 1998;225:13–35. 8. Pasteur L. De l’atte´ nuation des virus et de leur retour a` la virulence. C R Acad Sci III 1881;94:429 –35. 9. Greenfield WS. Lectures on some recent investigations into the pathology of infective and contagious diseases. Lecture III- Part I. Anthrax and anthracoid diseases. Lancet 1880;1:865–7. 10. Mahlandt BG, Klein F, Lincoln RE, Haines BW, Jones WI Jr, Friedman RH. Immunologic studies of anthrax: IV. Evaluation of the immunogenicity of three components of anthrax toxin. J Immunol 1966;96:727–33. 11. Puziss M, Manning LC, Lynch JW, Barclay E, Abelow I, Wright GG. Large-scale production of protective antigen of Bacillus anthracis in aerobic cultures. Appl Microbiol 1963;11:330 – 4. 12. Puziss M, Wright GG. Studies on immunity in anthrax. X. Geladsorbed protective antigen for immunization in man. J Bacteriol 1963;85:230 – 6. 13. Wright GG, Green TW, Kanode RG Jr. Studies on immunity in anthrax. V. Immunizing activity of alum-precipitated protective antigen. J Immunol 1954;73:387–91. 14. Welkos SL, Friedlander AM. Comparative safety and efficacy against Bacillus anthracis of protective antigen and live vaccines in mice. Microb Pathog 1988;4:53– 69. 15. Vaccine against anthrax. Br Med J 1965;5464:717– 8. 16. Anthrax vaccine. Med Lett Drugs Ther 1998; 40. 52–3. 17. Advisory Committee on Immunization Practices. Use of anthrax vaccine in the United States. MMWR Recomm Rep 2000;49:1–20. 18. Bail O. Research into natural and artificial anthrax immunity. Zentralb Bakteriol Parasitenkd Infectionskr 1904;47:270 –2. 19. Ivins BE, Fellows P, Pitt MLM. Efficacy of standard human anthrax vaccine against Bacillus anthracis aerosol spore challenge in rhesus monkeys. Salisbury Med Bull 1996;87(Suppl):125– 6. 20. Friedlander AM, Pittman PR, Parker GW. Anthrax vaccine: evidence for safety and efficacy against inhalational anthrax. JAMA 1999;282:2104 – 6. 21. Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA 1997;278:399 – 411. 22. National Communicable Disease Center. Investigational new drug application for anthrax protective antigen, aluminum hydroxide adsorbed. FDA no. DSB-IND 180, 1970. 23. Drugs and vaccines for biological weapons. Med Lett Drugs Ther 2001;43.87–9. 24. Young D. Anthrax vaccine offered, but not recommended, as option to treat infection. Am J Health Syst Pharm 2002;59:220 –5. 25. Committee on health effects associated with exposures during the gulf war, institute of medicine. In. Fulco CE, Liverman CT, Sox HC, eds. Gulf War and health. Volume I: Depleted uranium, sarin, pyridostigmine bromide, and vaccines. Washington, DC: National Academy of Sciences, 2000. Available at http://www.nap.edu/. 26. Peeler RN, Kadull PJ, Cluff LE. Intensive immunization of man: evaluation of possible adverse consquences. Ann Intern Med 1965; 63:44 –57. 27. White CS III, Adler WH, McGann VG. Repeated immunization: possible adverse effects. Reevaluation of human subjects at 25 years. Ann Intern Med 1974;81:594 – 600. 28. Swanson-Bierman B, Krenzelok EP. Delayed life-threatening reaction to anthrax vaccine. J Toxicol Clin Toxicol 2001;39:81– 4. 29. Greidanus TG, Honl BA. Delayed-type hypersensitivity reaction to anthrax vaccine. Mil Med 2002;167:74 –5. 30. Carlson JA, Mihm MC Jr, LeBoit PE. Cutaneous lymphocytic vasculitis: a definition, a review and a proposed classification. Semin Diagn Pathol 1996;13:72–90. 31. Sais G, Vidaller A, Jucgla´ A, Condom E, Peyrı´ J. Adhesion molecule expression and endothelial cell activation in cutaneous leukocytoclastic vasculitis. An immunohistologic and clinical study in 42 patients. Arch Dermatol 1997;133:443–50. 32. Zax RH, Hodge SJ, Callen JP. Cutaneous leukocytoclastic vascu-
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litis. Serial histopathologic evaluation demonstrates the dynamic nature of the infiltrate. Arch Dermatol 1990;126:69 –72. Bielsa I, Carrascosa M, Hausmann G, Ferra´ ndiz C. An immunohistopathologic study in cutaneous necrotizing vasculitis. J Cutan Pathol 2000;27:130 –5. Dvorak HF, Galli SJ, Dvorak AM. Cellular and vascular manifestations of cell-mediated immunity. Hum Pathol 1986;17:122–37. Massa MA, Su WPD. Lymphocytic vasculitis: is it a specific clinicopathologic entity? J Cutan Path 1984;11:132–9. Andrews BS, Cains G, McIntosh J, Petts V, Penny R. Circulating and tissue immune complexes in cutaneous vascultis. J Clin Lab Immunol 1979;1:311–20. Visaller A, Sais G. Cutaneous leukocytoclastic vasculitis: the dynamic nature of the infiltrate and expression of adhesion molecules (letter). J Cutan Pathol 2001;28:327–9. Imbus HR. Clinical evaluation of patients with complaints related to formaldehyde exposure. J Allergy Clin Immunol 1985;6:831– 40. Cockayne SE, McDonough AJ, Gawkrodger DJ. Occupational allergic contact dermatitis from formaldehyde resin in clothing. Contact Dermatitis 2001;44:109 –10. Kim CW, Song JS, Ahn YS, et al. Occupational asthma due to formaldehyde. Yonsei Med J 2001;42:440 –5. Kanerva L, Estander T, Jolanki R. Occupational allergic contact dermatitis from alkylammonium amidobenzoate. Eur J Dermatol 2001;11:240 –3. Fraki JE, Kalimo K, Tuohimaa P, Aantaa E. Contact allergy to various components of topical preparations for treatment of external otitis. Acta Otolaryngol 1985;100:414 – 8. Fisher AA. Reactions to aluminum and its salts. Cutis 1984;33: 154 –159. Slater DN, Underwood JCE, Durrant TE, Gray T, Hopper IP. Aluminum hydroxide granulomas: light and electron microscopic studies and x-ray microanalysis. Br J Dermatol 1982;107:103– 8.
A. E. Mun˜ iz 45. Veien NK, Hattel T, Justesen O, Noerholm A. Aluminum allergy. Contact Dermatitis 1986;15:295–7. 46. Kaaber K, Nielsen AO, Veien NK. Vaccination granulomas and aluminum allergy: course and prognostic factors. Contact Dermatitis 1992;26:304 – 6. 47. Cox NH, Moss C, Forsyth A. Allergy to non-toxoid constituents of vaccines and implications for patch testing. Contact Dermatitis 1988;18:143– 6. 48. Ivins BE, Wekos SL, Little SF, Crumrine MH, Nelson GO. Immunization against anthrax with Bacillus anthracis protective antigen combined with adjuvants. Infect Immun 1992;60:662– 8. 49. Ivins BE, Fellows PF, Nelson GO. Efficacy of a standard human anthrax vaccine against Bacillus anthracis spore challenge in guinea-pigs. Vaccine 1994;12:872– 4. 50. Miller J, McBride BW, Manchee RJ, Moore P, Baillie LW. Production and purification of recombinant protective antigen and protective efficacy against Bacillus anthracis. Lett Appl Microbiol 1998;26:56 – 60. 51. Little SF, Knudson GB. Comparitive efficacy of Bacillus anthracis live spore vaccine and protective antigen vaccine against anthrax in the guinea pig. Infect Immun 1986;52:509 –12. 52. Coulson NM, Fulop M, Titball RW. Bacillus anthracis protective antigen, expressed in Salmonella typhimurium SL 3261, affords protection against anthrax spore challenge. Vaccine 1994;12:1395– 401. 53. Baillie L, Moir A, Manchee R. The expression of the protective antigen of Bacillus anthracis in Bacillus subtilis. J Appl Microbiol 1998;84:741– 6. 54. Baillie LW, Moore P, McBride BW. A heat-inducible Bacillus subtilis bacteriophage phi 105 expression system for the production of the protective antigen of Bacillus anthracis. FEMS Microbiol Lett 1998;163:43–7. 55. Hanna P. How anthrax kills. Science 1998;208:1671,1673– 4.
doi:10.1016/S0736-4679(03)00201-4
Clinical Communications
LYMPHOCYTIC VASCULITIS ASSOCIATED WITH THE ANTHRAX VACCINE: CASE REPORT AND REVIEW OF ANTHRAX VACCINATION Antonio E. Mun˜iz,
MD, FACEP, FAAP
Department of Emergency Medicine and Pediatrics, Medical College of Virginia, Richmond, Virginia Reprint Address: Antonio E. Mun˜iz, MD, FACEP, FAAP, Department of Emergency Medicine and Pediatrics, Medical College of Virginia, 401 N. 12th Street, Richmond, VA 23298-0401
e Abstract—Anthrax is caused by the spore-forming bacteria Bacillus anthracis. It occurs naturally, but recently has been manufactured as a biological warfare agent. This makes prophylaxis for anthrax an urgent concern and efforts are ongoing for the production of an efficient and safe vaccine. Side effects to the current anthrax vaccine are usually minor and mainly consist of local skin reactions. Occasionally an unusual complication may occur; a case of a patient with lymphocytic vasculitis temporally associated with the anthrax vaccine is reported. © 2003 Elsevier Inc.
to the current anthrax vaccine are usually minor and mainly consist of local skin reactions (5,6). Occasionally, an unusual complication may occur, and in this article a patient with lymphocytic vasculitis temporally associated with the anthrax vaccine is reported.
CASE REPORT A previously healthy 53-year-old male Air Force Reserve Officer presented to our Emergency Department (ED) with a painful rash localized to the lower extremities. He reported receiving his fourth anthrax vaccination (BioPort Corporation, Lansing, MI) 11 days prior. Six days after receiving his anthrax vaccine he developed a low-grade fever, chills, and an erythematous rash on his feet and legs. Over the next few days, the rash became more erythematous and edema developed. He denied pruritus or arthralgias. He had no significant medical illnesses, took acetaminophen for pain and had no allergies. He denied any recent bacterial infections, tattoos, blood transfusions, chemical exposures, or any foreign travel, including being deployed to the Persian Gulf War. His initial vital signs were a blood pressure 115/71 mm Hg, heart rate 82 beats/min, respiratory rate 16 breaths/min, and temperature 38.1°C. Physical examination revealed a middle-aged man in mild discomfort from
e Keywords—lymphocytic vasculitis; anthrax vaccine
INTRODUCTION Anthrax is caused by the spore-forming bacteria Bacillus anthracis. In addition to causing naturally occurring anthrax, it has been manufactured as a biological warfare agent, a recent reality in the United States (1,2). Anthrax has been a focus of offensive and defensive biological warfare research programs for over 60 years (3). Development of new strains resistant to antibiotics or containing more powerful virulence factors could be the next batch of terrorist attacks, which could render our current antibiotic recommendations for prophylaxis and treatment powerless (4). This makes prophylaxis for anthrax an urgent concern and efforts are ongoing for the production of an efficient and safe vaccine (3,4). Side effects
RECEIVED: 21 June 2002; FINAL ACCEPTED: 5 March 2003
SUBMISSION RECEIVED:
29 January 2003; 271
272
A. E. Mun˜ iz
Figure 1. Patient’s lower extremity showing petechiae, purpura, scattered red macules, and edema.
pain. He had no lymphadenopathy. His lung and heart examinations were normal. He had no hepatosplenomegaly. His entire lower extremities had 3⫹ pitting edema. Both lower extremities had numerous petechiae, greater than 100, which became confluent as purpura in the lower part of the lower extremities (Figure 1). On the thigh there were scattered red macules, which blanched upon diskoscopy. Dermatology was consulted and a 4 mm punch biopsy was obtained. The white blood cell (WBC) count was 4900/mm3 with 71% neutrophils. The hemoglobin was 14.1 g/dL and platelets 193,000/mm3. Electrolytes, BUN, and creatinine were normal. The prothrombin time (PT) and activated partial prothrombin time (aPTT) were normal. The patient was discharged and returned to Dermatology clinic in 1 week to review the results of other laboratory tests. Rheumatoid factor was ⬍8 IU/mL, hepatitis A, B, and C panels were negative, Westergren sedimentation rate 25 mm/h, and the antinuclear antibody (ANA) was negative. The surgical histopathologic specimen showed superficial and mid-reticular dermal infiltrates, primarily lymphocytes. Local infiltration of lymphocytes within the walls of blood vessels was evident and extravasation of red blood cells was prominent. There was focal deposition of fibrin within the blood vessels and edema within the papillary dermis. Immunofluorescence studies showed vascular deposition of C3
and fibrin within the vessel walls. There was no IgA, IgM, C4, or C1q deposited. The histopathological and clinical impression was a lymphocytic vasculitis. He was reevaluated in the Dermatology clinic and symptoms resolved in 6 months.
DISCUSSION Anthrax is a zoonotic infection. Bacillus anthracis is a large, aerobic, Gram-positive bacterium whose endospores are found in the soil. Its high resistance to destruction makes it an ideal agent for a biological weapon. Human infection can result from abraded skin contact with either contaminated animals or animal products, or by inhalation or ingestion of endospores (7). Human anthrax occurs in three main forms: inhalational, cutaneous, and gastrointestinal. Recently, in the United States, cutaneous and inhalational anthrax have occurred from envelopes deliberately inoculated with anthrax spores. Unfortunately, inhalational anthrax presents with nonspecific symptoms that may not be easily distinguished from many more common diseases, especially influenza virus infections. In most cases, anthrax is usually not diagnosed until more recognizable symptoms occur, and by then the patient may die, despite appropriate antimicrobial therapy (1,2). Since the occurrence of recent anthrax cases, prevention of anthrax through a vaccina-
Anthrax Vaccine
tion program has become high priority in the United States. Bacillus anthracis possesses three known virulence factors, an antiphagocytic capsule and 2 protein exotoxins, lethal toxin, and edema toxin. The major virulence factors of B. anthracis are encoded on two virulence plasmids, pXO1 and pXO2, that carry the genes encoding various virulence factors. The toxin-bearing plasmid, pXO1, encodes for the genes that make up the secreted exotoxins. The toxin-gene complex is composed of protective antigen, lethal factor, and edema factor. The three exotoxin components combine to form two binary toxins, edema toxin and lethal toxin. Both plasmids are required for full virulence and the loss of either one results in an attenuated strain. In the past, bacterial strains used in the formulation of the anthrax vaccine were made by rendering virulent strains free of one or both plasmids. The Pasteur strain is the avirulent pXO2-carrying strain that is encapsulated but does not express exotoxin components (7). The Sterne strain is an attenuated strain that carries pXO1 and can synthesize exotoxin components but does not have a capsule (7). To date, the only known effective prevention against anthrax is through the administration of the anthrax vaccine. Because the incidence of all forms of naturally occurring anthrax, and most importantly the inhalational form, is exceedingly low, there is no opportunity to conduct new human trials for the effectiveness of vaccines against clinical anthrax. Furthermore, the high mortality rate associated with inhalational anthrax would ethically preclude any human challenge studies. Thus, we are left with the conundrum of how these previous field trials and experimental animal models translate to humans. The first vaccines that were administered to animals showed that inoculation of animals with attenuated strains of B. anthracis led to adequate protection from exposure to anthrax (8,9). Experimentation with filtrates of artificially or in vitro cultivated B. anthracis led to the formulation of the vaccine that is currently administered today (10 –12). The first nonlive vaccine, developed in 1954, was an aluminum potassium sulfate (alum)-precipitated cell-free filtrate from a B. anthracis aerobic culture (13). In the next few years the vaccine was improved by both using a strain of B. anthracis that produced a higher fraction of protective antigen and use of aluminum hydroxide as the adjuvant (11,12). This vaccine is believed to stimulate humoral but not cell-mediated immunity (14). This is the only licensed anthrax vaccine in the United States and is termed Anthrax Vaccine Adsorbed (or AVA). It is an aluminum hydroxide-precipitated preparation (BioPort Corporation) of protective antigen from attenuated, nonencapsulated B. anthracis cultures of the Sterne strain known as V770-NP1-R (11,15–17).
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The filtrate contains a mixture of cellular products, including all three components, lethal factor, edema factor, and protective antigen, and is adsorbed to aluminum hydroxide (Amphogel, Wyeth Laboratories, Madison, NJ) as adjuvant (16,18). The efficacy of AVA is based on several animal studies and immunogenicity data for both humans and animals. There are no prospective, randomized, placebocontrolled human clinical studies using AVA. In rhesus monkeys, inoculations with AVA afforded substantial protection against inhalational anthrax (13,19,20). There are very limited trials in humans that show a similar protection against cutaneous anthrax (5). The standard vaccine in the United States was approved by the Food and Drug Administration in 1970 and is routinely administered to people at risk for exposure to anthrax spores. People at risk include individuals who may come in contact with animal products at risk to be contaminated with Bacillus anthracis spores, individuals engaged in diagnostic or investigational activities that may bring them in contact with B. anthracis spores, and persons at high risk, such as veterinarians and others handling potentially infected animals. However, the vaccine has not been manufactured since February of 1998. Due to the current world threat of biological warfare, Secretary of Defense William S. Cohen made it mandatory to vaccinate the United States Armed Forces. Thus, all the remaining supplies of the vaccine are currently being given to immunize all military personnel and are not available for civilian use. It is the goal of the military to have all 2.4 million Active, Guard, and Reserve service members inoculated by 2003 (4). AVA is administered subcutaneously in a series of 0.5-ml doses at 0, 2, and 4 weeks, then at 6, 12, and 18 months (19,21). Thereafter, annual booster doses are administered. Adverse effects of the vaccine were first encountered during the prelicensure evaluation of 6,985 people who received 16,435 doses (22). Mild local reactions occurred in 3–20% of vaccinations, moderate reactions occurred in 1–3%, whereas only 1% had severe local reactions. Most of the reactions included erythema, tenderness, and edema commonly at the site of inoculation. Systemic reactions, such as malaise, fever, chills, body aches, nausea, headache, and myalgia occurred in ⬍0.06% (22,23). Since March 10, 1998, the active Anthrax Vaccine Immunization Program has given AVA to military personnel. To monitor the incidence of adverse reactions from vaccines, the Food and Drug Administration and Centers for Disease Control and Prevention jointly developed the Vaccine Adverse Event Reporting System (VAERS) in 1990 (6). The Department of Defense policy encourages health care providers to report all adverse events possibly associated with AVA vaccination and
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specifically requires all adverse events resulting in loss of duty more than 24 h or hospitalization to be reported. Reporting to the VAERS can be performed by a health care provider, patient, or anyone else. The report of an adverse event to VAERS is not confirmation that the vaccine caused the event, only that the event occurred in a temporal relationship with the vaccine administration. Because it is difficult to distinguish a coincidental from a causative event, the VAERS database, a passive surveillance system, contains all reports. From January 1, 1990 through November 29, 2001 there have been 2,098,544 doses of anthrax vaccines with 1,685 reports of adverse events (24). Serious events are defined as death, life threatening, hospitalization, or any permanent disability. Of the reported adverse events, there were 76 (5%) serious events. The most frequently reported adverse events were injection-site hypersensitivity, injection-site edema or pain, headache, arthralgia, asthenia, and pruritus. Anaphylaxis has occurred only in 2 patients. Likewise, death has been reported in 2 patients; one had an autopsy with a final diagnosis of coronary arteritis and the second had aplastic anemia. The cause of these deaths has not been definitely linked to anthrax vaccine. Other serious events have included cellulitis, Guillain-Barre´ syndrome, pneumonia, seizures, cardiomyopathy, multiple sclerosis, collagen vascular disease, systemic lupus erythematosus, sepsis, angioedema, and tranverse myelitis (3). Formal analysis of VAERS data demonstrates no pattern of serious adverse events clearly associated with the vaccine, except that of primary local injection-site reactions. The limitation of the VAERS data is that it is a self-reporting system and it is often very difficult to determine the exact etiology of the reported event. For a variety of reasons, vaccine-related adverse events may not have been reported to VAERS. Some members of the armed forces, especially those in the reserves, are likely to seek medical attention from their personal physicians. In addition, the possibility that a relationship exists between the symptoms and the anthrax vaccine may not be apparent to either the patient or the physician. Other pressures may also hinder reporting, such that reporting these events may make them not suitable for full active duty, and thereby may negatively influence their military careers. The Institute of Medicine, in an assessment of a few short-term studies, reported no significant adverse effects after the anthrax vaccination (25). A 25-year surveillance of anthrax vaccine at Fort Detrick did not reveal any unusual illnesses or unexplained symptoms (26,27). A delayed anaphylactoid reaction and delayed-type hypersensitivity reaction temporally related to an anthrax vaccination have been reported (28,29). There have been no reports of the occurrence of chronic diseases associated with the anthrax vaccine.
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In the case reported, there was a close relationship between the anthrax vaccination and the development of lymphocytic vasculitis. Cutaneous lymphocytic vasculitis is a clinicopathological process characterized by lymphocytic inflammation of, and damage to, dermal blood vessels. It is accompanied by fibrin deposition in the blood vessel walls or lumens, or both (30). The syndrome is presumed to be associated with an aberrant hypersensitivity reaction to an antigen such as an infectious agent, drug, or other foreign or endogenous substance. There have been multiple mechanisms implicated, such as circulating antigen-antibody complexes, type IV delayed hypersensitivity reactions, and cell-mediated or endothelial attack by lymphocytes (31–34). Elevations of serum immunoglobulin levels are relatively common with lymphocytic vasculitis (35). IgA and IgM are more commonly elevated than IgG (35,36). Immunofluorescent studies have shown vascular deposits of IgG or C3 (35,36). These findings also have been seen in erythema multiforme, pigmentary purpura, and pityriasis lichenoides et varioliformis acuta (37). In the patient reported here it is unclear whether the vasculitis was due to an altered immune system response to the antigens in the vaccine or to the presence of either the preservative or adjuvant agents. AVA contains benzethonium chloride as a preservative and formaldehyde as a stabilizer. There is limited information about the effects that these preservatives or adjuvant agents may have on humans. Review of the current medical literature [Medline from 1966] shows no reports of vasculitis caused from any of these agents. Formaldehyde is a known sensitizer, responsible for asthmatic reactions, ocular and dermal irritation (38 – 40). Benzethonium chloride, often found in topical medications, has been implicated in a limited number of cases of contact dermatitis (41,42). Aluminum hydroxide has been shown to be a weak skin irritant and has caused granuloma years after an injection of adsorbed diphtheria, tetanus, and pertussis (DTP) vaccine (43– 46). Others have reported pruritus, dermatitis, hyperpigmentation, or hypertrichosis (47). Therefore, it seems that the vasculitis is more likely a result of an abnormal immunologic response to the bacterial antigen than to the vaccine excipients. Problems with the AVA such as complex dosing schedule, and high incidence of local reactions has prompted newer vaccines to be tested that may be easier and more practical to administer. The newer vaccines should ideally generate both cell-mediated as well as humoral immunity, and inhibit spore germination. These newer vaccines may include preparations of protective antigen subunits with different adjuvants, protective antigen purified from recombinant sources, and live vaccines based on anthrax strains with auxotrophic mutations (48 –54). The ability of any of these new vaccines
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to protect humans in the event of a widespread aerosol attack of biological warfare is not known (55). With advances in biotechnology and allegations that recombinant strains of anthrax with greater virulence factors than the native strains are likely to be formulated, it is possible that the current generation of vaccine will not be protective. Furthermore, it may take years to develop, license, manufacture, administer, and confer immunity using newly formulated vaccines. Even if the anthrax vaccine is found to be highly effective against a potential biological warfare, other factors may preclude its widespread implementation. Many military personnel have recently refused to take the anthrax vaccination, despite being the most likely population to initially encounter the threat. In addition, many parents refuse to administer to their children approved vaccinations against common diseases for fear of their rare complications. Although there is probably a role for the anthrax vaccine, it should not be expected to provide a robust biological defense.
CONCLUSIONS The threat of biological warfare by means of inhalational anthrax is an unfortunate reality. The risk assumed from the employment of a large-scale anthrax vaccination program must be weighed against the risk of no prevention, namely, a mass number of fatalities incurred from exposure to inhalational anthrax. The major advantage of a vaccination program is the potential prevention of fatalities from what is generally accepted as a lethal exposure versus the transient, predominantly local adverse vaccine reactions. Although a rare, previously unknown adverse effect, such as lymphocytic vasculitis, may occur, there is no scientific evidence to date that such problems have been reported in any significant amounts in nearly 30 years experience with the use of AVA.
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