In the absence of a known release, the discovery of a patient with characteristic findings of a disease caused by a Category A agent should prompt further investigation, as well as the institution of appropriate infection control measures Perhaps an ED triage nurse discovers that within a short period of time two separate infants arrive with complaints of floppiness and weakness, raising the concern for infant botulism Perhaps a pediatric resident becomes concerned about a viral hemorrhagic fever after encountering a highly febrile and illappearing child with a purpuric rash who recently traveled to Africa Although not all of the Category A biologic agents are spread from person to person ( Table 132.3A ), in these cases it would be prudent to assume this mode of spread The staff member, after washing his hands, should put on a gown, gloves, and eye protection An N-95 respirator should be added if there is concern for smallpox or viral hemorrhagic fever The child should be covered with a sheet, provided a mask, and escorted directly to a negative-pressure room for further evaluation and treatment CLINICAL ASSESSMENT AND MANAGEMENT Specific Agents Anthrax CLINICAL PEARLS AND PITFALLS Inhalational anthrax should be suspected when there is fever with a widened mediastinum on chest x-ray in the absence of trauma Inhalational anthrax is not contagious and therefore poses no risk to healthcare workers Background Anthrax is caused by infection with Bacillus anthracis, a grampositive spore-forming rod capable of surviving long periods in its spore form without nutrients or moisture Natural disease caused by B anthracis manifests in cutaneous, gastrointestinal (GI), and inhalational forms Anthrax spores can be formulated in a manner to enhance aerosolization The resulting small particles may drift long distances with air currents, produce lethal infection when inhaled, and resist environmental degradation, making them a formidable terrorist weapon The anthrax attacks of 2001 resulted in 22 confirmed cases (11 inhalational, 11 cutaneous), with five deaths, resulting from presumed or known exposure to