The primary care differential diagnosis of inhalational anthrax

PURPOSE: Inhalational anthrax is an extremely rare infectious disease with nonspecific initial symptoms, thus making diagnosis on clinical grounds difficult. After a covert release of anthrax spores, primary care physicians will be among the first to evaluate cases. This study defines the primary care differential diagnosis of inhalational anthrax. METHODS: In May 2002, we mailed survey instruments consisting of 3 randomly chosen case vignettes describing patients with inhalational anthrax to a nationwide random sample of 665 family physicians. Nonrespondents received additional mailings. Physicians were asked to provide their most likely nonanthrax diagnosis for each case. RESULTS: The response rate was 36.9%, Diagnoses for inhalational anthrax were grouped into 35 diagnostic categories, with pneumonia (42%), influenza (10%), viral syndrome (9%), septicemia (8%), bronchitis (7%), central nervous system infection (6%), and gastroenteritis (4%) accounting for 86% of all diagnoses. Diagnoses differed significantly between cases that proved to be fatal and those that proved to be nonfatal. CONCLUSIONS: Inhalational anthrax resembles common diagnoses in primary care. Surveillance systems for early detection of bioterrorism events that rely only on diagnostic codes will be hampered by false-positive alerts. Consequently, educating front-line physicians to recognize and respond to bioterrorism is of the highest priority.