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Am Fam Physician. 2002;65(9):online-only-

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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