Diagnostic testing for suspected anthrax

Clinical syndrome suspected	Specimen	Testing
Cutaneous anthrax*^¶	Lesion swabs: Vesicular lesions: Two swabs of vesicular fluid from an unopened vesicle Eschars: Two saline-moistened swab samples, rotated underneath the eschar Ulcers: Sample the base of the lesion with two saline-moistened swabs	Culture (one swab)^Δ PCR testing (one swab)
	Biopsy (full-thickness) of papule or vesicle, including adjacent skin	Histopathology Special stains IHC
	Serum, acute and convalescent^◊	Serology
	Plasma	Anthrax lethal factor toxin testing (can also be performed on acute serum)
Inhalation anthrax^¶	Blood	Culture^Δ PCR testing
	Serum, acute and convalescent^◊	Serology
	Plasma	Anthrax lethal factor toxin testing (can also be performed on acute serum)
	Pleural fluid, if present	Culture^Δ PCR testing Anthrax lethal factor toxin testing
	Pleural and/or bronchial biopsy specimens	IHC
Gastrointestinal anthrax^¶	Blood	Culture^Δ PCR testing
	Serum, acute and convalescent^◊	Serology
	Plasma	Anthrax lethal factor toxin testing (can also be performed on acute serum)
	Oropharyngeal lesion swab, if present	Culture^Δ PCR testing
	Ascites fluid	Culture^Δ PCR testing Anthrax lethal factor toxin testing
	Rectal swab	Culture^Δ PCR testing
Anthrax meningitis	Blood	Culture^Δ PCR testing
	Serum, acute and convalescent^◊	Serology
	Plasma	Anthrax lethal factor toxin testing (can also be performed on acute serum)
	Cerebrospinal fluid	Culture^Δ PCR testing
Injection anthrax^¶	Blood	Culture^Δ PCR testing
	Serum, acute and convalescent^◊	Serology
	Plasma	Anthrax lethal factor toxin testing (can also be performed on acute serum)
	Biopsy from tissue debridement	Histopathology Special stains IHC
Fatal cases	Autopsy tissue	Histopathology Special stains IHC

In the United States, clinicians should consult with their state health department to review specimen collection and transport to a reference center.

IHC: immunohistochemistry; PCR: polymerase chain reaction.

* If there are signs of systemic anthrax infection (ie, febrile or hypothermia, tachycardia, tachypnea, hypotensive), collect blood specimen before starting antimicrobial therapy for culture and real-time PCR.

¶ Evaluation for meningitis with cerebrospinal fluid testing is warranted for all manifestations of systemic anthrax (including inhalational and gastrointestinal anthrax) and in patients with anthrax who have severe headache, meningeal signs, altered mental status, seizures, focal neurologic deficit, or sepsis.

Δ Whenever possible, specimens submitted for culture should be collected prior to antibiotic administration.

◊ An acute specimen is collected ≤7 days after symptom onset or as soon as possible after a known exposure event. A convalescent specimen is collected 14 to 35 days after symptom onset.

Adapted from: Recommended specimens for anthrax testing by clinical presentation. Centers for Disease Control and Prevention. https://www.cdc.gov/anthrax/lab-testing/recommended-specimens/clinical-presentation.html (Accessed on April 10, 2023).

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Diagnostic testing for suspected anthrax