to the editor: Unfortunately, in cases such as those outlined in the "Photo Quiz" item entitled "A Widened Mediastinum,"¹ acute inhalation anthrax infection must now, unarguably, be added to the differential diagnosis for the cause of acute descending necrotizing mediastinitis.

Drs. Bhargava and Iqbal state that a review of the literature revealed only 69 cases of acute descending necrotizing mediastinitis between 1960 and 1995.² Just as in necrotizing mediastinitis, a characteristic finding on computed tomographic scan associated with hemorrhagic mediastinitis is symmetric mediastinal widening.³ The clinical presentation of the patient in the “Photo Quiz” was described as initial symptoms of mild upper respiratory tract infection progressing to frank respiratory distress within a timeframe of three to four days—a scenario that is also indicative of acute inhalation anthrax infection.^4,5

As I write this letter, I have just learned that two postal workers in Washington, D.C., have died of acute inhalation anthrax.