Sputum cultures might have a higher yield, particularly if anthrax is specifically looked for. The second phase develops suddenly with the development of severe shortness of breath and cyanosis. Hypotension and shock occur. The temperature may be elevated or subnormal due to shock, and perspiration is often profuse. Stridor may be present due to enlargement of the lymph nodes near the trachea.
Chest exam shows moist, crepitant rales and signs of pleural effusion.
Blood cultures are positive, and the bacteremia may be high enough for organisms to be visible on a Gram stained smear. The second, acute phase typically lasts less than 24 hours and usually ends in death despite therapy, due to the high number of toxin-producing organisms present by this stage in the illness. No data are available on the value on penicillin IM, but it would likely be less effective and larger doses might be required. In a biological warfare situation, however, I would recommend that vancomycin be a part of any regimen, in a dose of 500 mg every 6 hours. Intramuscular injection of vancomycin is painful.