Anthrax may present differently in children

Are children less susceptible or underdiagnosed?

It appears the old adage in pediatric medicine — "children are not little adults" — holds true for anthrax infection. The limited data available on children with anthrax suggest that their clinical presentation may differ from adults with anthrax. Clinicians and public health officials should be aware of these differences for the timely diagnosis of children with anthrax and for the development of syndromic surveillance tools for populations that include pediatric patients, according to a report by the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD.1

For example, children with inhalational anthrax may have atypical presentations including primary meningoencephalitis. The study found that children with inhalational anthrax did have abnormal chest roentgenograms, but children with other forms of anthrax often had normal roentgenograms. Thus, the usefulness of roentgenograms in the early diagnosis of noninhalational anthrax disease may be limited, the report states.

In response to the 2001 U.S. anthrax attacks, there has been a proliferation of guidelines for the diagnosis and treatment of patients with anthrax. However, most of these have not specified screening and management protocols for specific populations, such as children. The AHRQ researchers performed a systematic review of case reports of pediatric anthrax to describe the clinical course, treatment responses, and predictors of disease progression and mortality for children with anthrax infection.

Among the 59 case reports that stated the patient's gender, only 14 (24%) were girls. That is similar to the gender discrepancy observed among adults, the report notes. Plausible explanations for the gender disparity include that anthrax has largely been an occupational disease among professions traditionally dominated by men and boys (e.g., woolsorters and butchers). There also may be biases that result in the underdiagnosis and undereporting of girls with anthrax. Overall, the mortality rate for pediatric anthrax was 31%. Among patients who received antibiotics, 71% survived compared to 82% of patients who received antiserum.

"Antiserum is not typically included in current treatment guidelines or bioterrorism preparedness inventories," the report observes. "Similarly, current treatment guidelines do not include penicillin as a single agent due to concerns of penicillin resistant organisms . . . In the event of shortfalls in stockpiles of the currently recommended antibiotics, penicillin or antiserum may provide some therapeutic benefit."

Though anthrax is a relatively common and historically well-recognized disease, it is rarely reported among children. "We did not find evidence to support or refute the claim that children may be less susceptible to anthrax infection," the authors conclude. "In general, the relatively small number of pediatric cases of anthrax may reflect that this has traditionally been an occupational disease so that, particularly young children, may not have the same degree of exposure to anthrax spores."

However, the paucity of pediatric anthrax case reports suggests that anthrax may be underdiagnosed in children. Underdiagnosis and underreporting of anthrax is likely to occur because the presenting symptoms for pediatric inhalational anthrax are very common for many childhood diseases. Moreover, since acute respiratory infections are the second-leading cause of death worldwide for children younger than 5 years old, it is highly likely that naturally occurring pediatric anthrax has been attributed to one of the common childhood respiratory infections, the report notes. Additionally, naturally occurring anthrax disease is most prevalent in poor countries with few health care resources and high infant mortality rates, where children never may come to medical attention or have diagnostic cultures confirmed.


  1. Agency for Healthcare Research and Quality Pediatric Anthrax: Implications for Bioterrorism Preparedness AHRQ Publication No. 06-E013; August 2006. Web: