Bioterrorism

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Bioterrorism

• PLAGUE

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Learning Objectives

• Describe epidemiologic features favoring a
  bioterrorism scenario with plague
• Describe Y. pestis morphology
• List isolation precautions required for patients
  suspected of having plague
• List transmission routes for plague
• Describe therapeutic options for patients with
  suspected plague

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Ancient rootsbut still here
http//www.cdc.gov/ncidod/dvbid/plague/epi.htm
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Case Presentation

• Youre an ED physician practicing in Miami, FL.
  Youre tired because you were up late watching
  the presidential candidates debate before
  upcoming elections.
• You just received sign-out from your colleague
  who is concerned about a previously healthy 37 yo
  male patient who presented with severe CAP. You
  pick up a chart from the rack and note that your
  next patient is a 36 yo female complaining of
  SOB.
• You open the curtain and are immediately
  impressed by your new patients dyspnea and
  pallor.
• The patient reports that she was well the day
  prior. She awoke this am with profound weakness,
  chills, and chest discomfort. Her cough
  progressed over the morning and noting blood in
  sputum, she came to the ED. ROS reveals some
  vague nausea and abdominal pain.

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Case presentation contd

• PMH/PSH unremarkable and the patient has NKDA
• Soc hx reveals an occasional smoker. She is in a
  monogamous relationship, and denies IV or inhaled
  illicit drug use. She has no recent travel
  outside the US, but is in town working on the
  debate team for one of the presidential
  candidates.
• PE reveals a pale tachypneic female. HR 100 RR
  28 BP 90/60 T 102.3 and pulse ox of 83 on RA.
  Lung exam with rhonchi and egophony in the left
  mid lung field. She is tachycardic without an
  appreciable murmur. Abdomen is mildly tender
  diffusely. She has no rash.
• LABS WBC 28 with 30bands hgb 11.2 plt 450.
  BUN/Cr 18/1.3
• CXR shows

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DDX

• CAP (pneumococcus, legionella)
• Anthrax
• Influenza
• ?SARS
• ?PCP/HIV
• Pulmonary embolism
• ?Viral Hemorrhagic Fever

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Blood smear reveals
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What is Plague?

• Yersinia pestis
• gram-negative coccobacillus
• Plague Syndromes
• Bubonic
• Pneumonic
• Septicemic

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What is Plague?

• Transmission small rodent reservoir
• BUBONIC
• PNEUMONIC

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Epidemiology

• Naturally Occurring
• Bubonic
• - Isolated cases
• - SW United States
• - April-October and hunting season
• - Preceding rodent die-off

• Bioterrorism
• - Pneumonic (highly infectious)
• - Large clusters
• - Metropolitan cities
• No seasonality
• - Lack of rodent die off

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Pneumonic Plague-Primary

• Incubation periods 1-3 days
• Clinical manifestations
• Sudden onset fever, chills, HA, weakness, chest
  discomfort
• Rapid progression pulmonary sx
• Intense cough with thin sero-sang. Sputum
• Radiology
• Lobar pneumonia, pleural effusion, ARDS

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Less common Plague syndromes

• Plague pharyngitis
• Similar to streptococcal or viral pharyngitis
• Plague Meningitis
• May be primary but usually occurs 1 week after
  septicemic or bubonic (?axillary)
• Often associated with delayed/static rx

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Laboratory diagnosis

• Direct examination sputum, blood, buboe aspirate
• Gram stain, Giemsa or Wayson stain
• gram negative coccobacillus
• Bipolar staining
• Cultures positive within 24-48 hours

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Treatment

• Aminoglycosides, Ciprofloxacin, Doxycycline,
  Chloramphenicol x 10days
• Do NOT use cephalosporins

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Post exposure treatment and prophylaxis

• The following patients require isolation and IV
  antibiotics
• All people with fever gt 101
• All people with cough
• Infants with tachypnea
• Asymptomatic people within 2 meters of an
  untreated case should take PO antibiotics
• Ciprofloxacin, Doxycycline for 7 days

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Vaccination

• Vaccine is not currently available
• Does not prevent or ameliorate primary pneumonic
  plague

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Infection Control

• Isolation of patient until 48h of adequate rx
• Droplet precautions
• Surgical mask, gown, gloves, eye shield
• Close contacts who refuse prophylaxis much be
  watched carefully x 7 days
• Alert hospital personnel
• Limit aerosol-generating procedures

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Plague Questions
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Question 1

• In which of the following scenarios would you
  suspect bioterrorism?
• Several pt with acute resp sx in NYC
• Prairie-dog hunter with painful lump in armpit
• Single patient with acute pneumonia and tender
  lymphadenopathy in N. Arizona

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Question 2

• Sputum gram-stain will show
• Gram-positive diplococci
• Gram-positive rods
• Gram-negative coccobacilli
• Gram-negative rods
• Gram stain usually negative

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Question 3

• Which of the following isolation measures is
  appropriate for a pt. with pneumonic plague?
• N-95 mask, gown, gloves, goggles until anbx for 1
  week
• Surgical mask, gown, gloves, goggles until anbx
  for 1 week and clinically better
• Surgical mask, gown, gloves, goggles until anbx
  for 48-72 hours and clinically better

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Question 4

• Transmission of plague occurs via all of the
  following except
• Bite from a flea
• Bite from a rodent
• Cough from infected person within 2 meters
• Standing water after a flood

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Question 5

• Treatment options for a pt. with pneumonic plague
  include which list
• doxycycline, rifampin for 9 months
• Doxycycline, Ciprofloxacin for 10 days
• Aminoglycoside, Ceftriaxone for 60 days
• Chloramphenicol, Ceftazidime for 7 days

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This completes the current presentation.