epidemiologic purposes, although positive nasal swabs not prove penetration of toxin to the lungs, and negative swabs not exclude exposure in any given patient In addition, assays for the presence of toxin, as well as measurement of an antibody response, can be performed on serum Management is primarily supportive, although the U.S military has found that postexposure prophylaxis with an investigational toxoid is efficacious in animal trials OTHER AGENTS Numerous other agents may present bioterrorist threats of varying degrees In addition to previously discussed incidents, terrorists and belligerents have attempted to use Salmonella, Shigella, glanders, cholera, typhus, and probably many other organisms or toxins to induce disease Many of these agents are discussed adequately elsewhere in this and other texts; a few warrant additional comment here Venezuelan equine encephalitis makes an attractive weapon because of its high infection-to-disease ratio; virtually all those who are not immune become symptomatic In infants and young children the disease can be severe, with as many as 4% developing overt encephalitis, often leading to permanent sequelae or death Staphylococcal enterotoxin B (SEB) is a bacterial toxin that has been weaponized in the past Although familiar to many clinicians as a common cause of food poisoning, SEB would also be a potent incapacitating toxin if delivered by aerosol Symptoms produced in this manner would begin to 12 hours after exposure and consist of fever, headache, chills, myalgias, and nonproductive cough Dyspnea and chest pain accompany the inhalation of high dosages of inhaled toxin Nausea, vomiting, and diarrhea may occur as a result of inadvertently swallowed toxin Treatment is supportive; meticulous attention should be paid to fluid management Patients may be ill for as long as weeks with aerosol exposure Various fungal toxins, such as the trichothecene mycotoxins, have been mentioned in a biowarfare or bioterrorism context After the Vietnam War, the U.S government accused the Soviets of using a trichothecene toxin, T-2 mycotoxin (otherwise known as “yellow rain”), against Hmong tribesmen The Iraqis are known to have weaponized another fungal toxin, aflatoxin, which in addition to acute clinical effects, is a potent hepatic carcinogen Symptoms produced by various mycotoxins are variable and depend on the route of exposure The trichothecene mycotoxins are different from virtually all other bioterrorist agents in that they are dermally active Treatment is supportive