If several people near each other develop fever, cough, and pulmonary edema, what bioterror attack might have occurred?

• A. Bacillus anthracis
• B. Smallpox
• C. Abrin or Ricin
• D. Tularemia

Answer: (C)

When several people close together develop fever and cough followed by pulmonary edema, think of a toxic inhalational exposure causing rapid capillary leak rather than a contagious infectious illness. Abrin or ricin inhalation fits this pattern well, because these plant-derived toxins damage respiratory epithelium and the capillary endothelium, leading to noncardiogenic pulmonary edema and respiratory failure within hours of exposure. In a bioterrorism scenario, a cluster of cases with fast-onset pulmonary edema from a single source is a hallmark of inhaled ricin or abrin.

Bacillus anthracis can cause a severe inhalational illness with fever and dyspnea, but the classic feature is mediastinal widening from lymphatic involvement rather than pulmonary edema as the defining presentation. Smallpox centers on a characteristic vesicular-pustular rash, not edema. Tularemia can cause pneumonic disease but does not typically present with rapid pulmonary edema in a cluster.