1. Plague Bioterrorism PLAGUE

2. Plague 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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4. Ancient roots…but still here http://www.cdc.gov/ncidod/dvbid/plague/epi.htm

5. Plague Case Presentation You’re an ED physician practicing in Miami, FL. You’re 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 patient’s 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.

6. Plague Case presentation cont’d 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 30%bands hgb 11.2 plt 450. BUN/Cr 18/1.3 CXR shows…

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

9. Plague Blood smear reveals:

10. Plague What is Plague? Yersinia pestis: –gram-negative coccobacillus Plague Syndromes –Bubonic –Pneumonic –Septicemic

11. Plague What is Plague? Transmission: small rodent reservoir –BUBONIC –PNEUMONIC

12. Plague 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

13. Plague 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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15. 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

16. Plague 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

17. Plague Treatment Aminoglycosides, Ciprofloxacin, Doxycycline, Chloramphenicol x 10days Do NOT use cephalosporins

18. Plague Post exposure treatment and prophylaxis The following patients require isolation and IV antibiotics: –All people with fever > 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

19. Plague Vaccination Vaccine is not currently available Does not prevent or ameliorate primary pneumonic plague

20. Plague 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

21. Plague This completes the current presentation.