anthrax-contaminated mail The attack resulted in enormous public anxiety, as well as major demands for medical care and public health resources Antibiotic prophylaxis was prescribed for more than 30,000 persons, and decontamination of the Hart Senate Office Building alone took months and was extremely costly Many bioterrorism defense experts, however, fear an even more widespread aerosol release that could potentially sicken hundreds of thousands Inhalational anthrax is the disease form that poses the greatest threat Following the accidental release of anthrax spores from a Soviet military facility at Sverdlovsk in 1979, 66 of 77 known victims of inhalational anthrax died In the recent U.S attack, all deaths occurred among the 11 patients with this form of disease Pathophysiology/Common Manifestations Inhalational anthrax results from spore uptake in the alveoli by pulmonary macrophages, followed by bacterial germination and toxin production in the mediastinal lymph nodes, leading to hemorrhagic lymphadenitis, mediastinitis, and sepsis Symptoms typically begin to days after exposure, although incubation periods up to several weeks in length have been reported The disease begins as a nonspecific influenza-like illness, characterized by fever, headache, myalgia, and cough The relative lack of eye, nose, and throat findings such as red, watery eyes, rhinorrhea, or pharyngitis helps to distinguish this phase from common viral infections A brief intervening period of improvement sometimes follows, but rapid deterioration then ensues with high fever, dyspnea, cyanosis, and shock marking this second phase Hemorrhagic meningitis occurs in up to 50% of cases Chest radiographs or computed tomography scans may reveal a widened mediastinum or prominent mediastinal lymphadenopathy; infiltrates and pleural effusions may also be seen Gram stains of peripheral blood smears at this stage may demonstrate grampositive rods Prompt treatment is imperative as, historically, death occurred in as many as 95% of inhalational anthrax cases if such treatment began more than 48 hours after symptom onset Even with modern intensive care, in the 2001 anthrax attack, all four patients with inhalational anthrax who exhibited signs of fulminant disease prior to antibiotic administration died Thus, in the context of a known bioterrorism incident, a potential dilemma facing emergency care providers involves deciding which patients presenting with nonspecific flu-like, febrile illness are candidates for empiric antibiotic therapy Cutaneous anthrax occurs when organisms gain entry into skin, usually through abrasions or cuts It is characterized by the appearance of a papule at the inoculum site, which then progresses over days to a vesicle, then to an ulcer, and