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plague

Etiology: infection with Yersinia pestis Epidemiology: 1) more prevalent in New Mexico, Arizona, Colorado & California than other states 2) great plague of Europe 1400-1600 killing 25% of population 3) spread from wild rodents & occasionally cats either directly or by fleas 4) primarily a disease of rodents 5) pneumonic plague is transmitted through aerosolized Yersinia pestis or person-to-person transmission via respiratory droplets [4] 6) 10-15 cases in USA annually [6] 7) outbreak of 4 cases in June & July of 2014 in Colorado origating from an infected dog [8] 8) 11 cases April-August 2015 in Arizona, California, Colorado, Georgia, New Mexico, & Oregon Clinical manifestations: 1) incubation period is 2-7 days 2) 3 clinical syndromes a) pneumonic plague from inhalation of Yersinia pestis - fulminant lethal form - sudden onset high fever - pleuritic chest pain - productive cough - hemoptysis b) bubonic plague is the most common form (85%) - purulent lymphadenitis near the site of inoculation - intensely painful group of swollen lymph nodes (bubo) - acral gangrene [11] c) septicemic plague can arise from pnuemonic plague or bubonic plague 3) general a) high fever b) headache c) lymph node enlargement (bubo, axilla & groin) d) petechiae e) hemorrhage from mucous membranes f) cough g) tachypnea h) pneumonia (10-20%) i) sepsis 4) case report [9] - fever - cough with scant hemoptysis - chest pain - myalgias Laboratory: 1) leukocyte count > 15,000/mm3 2) diagnosis made from blood, lymph nodes & sputum a) Giemsa staining - gram-negative coccobacilli with bipolar staining (closed safety pin appearance) b) culture c) direct fluorescent antibody 3) serology Radiology: - chest X-ray: a) bilateral lower lobe alveolar infiltrates b) pleural effusion is common c) nodules & cavitation may occur Differential diagnosis: - tularemia Complications: - pneumonic plague is 100% lethal if not treated within 24 hours Management: 1) treatment for 7-10 days with a) streptomycin or gentamicin (1st line [4]), or b) doxycycline, or c) ciprofloxacin, levofloxacin, moxifloxacin [5] 2) patients must be isolated for 48 hours until it is determined that disease has not progressed to pneumonic form 3) post-exposure prophylaxis - doxycycline, or ciprofloxacin, levofloxacin for 7 days Notes: - potential agent of bioterrorism [7] - British nursery rhyme [15] - ring around the rosy rash, was a symptom of the plague - posies of herbs were carried as protection and to ward off the smell of disease - A-tishoo! A-tishoo! sneezing a final fatal symptom - 'all fall down' was exactly what happened [15]

Related

Yersinia pestis

General

flea (Siphonaptera)-borne infection bacterial infection

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 798-99
  2. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  3. Centers for Disease Control and Prevention (CDC). Human plague--four states, 2006. MMWR Morb Mortal Wkly Rep. 2006 Sep 1;55(34):940-3. PMID: 16943764
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16. 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021.
  5. FDA News Release: April 27, 2012 FDA approves new antibacterial treatment for plague http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm302220.htm - FDA News Release. May 8, 2015 FDA approves additional antibacterial treatment for plague http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm446283.htm
  6. Prentice MB, Rahalison L. Plague. Lancet. 2007 Apr 7;369(9568):1196-207. PMID: 17416264
  7. Inglesby TV, Dennis DT, Henderson DA Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. 2000 May 3;283(17):2281-90. PMID: 10807389
  8. Runfola JK, House J, Miller L et al Outbreak of Human Pneumonic Plague with Dog-to-Human and Possible Human-to-Human Transmission - Colorado, June-July 2014. MMWR Morb Mortal Wkly Rep. 2015 May 1;64(16):429-34. PMID: 25928467
  9. Foster CL, Mould K, Reynolds P et al Sick as a Dog N Engl J Med 2015; 372:1845-1850. May 7, 2015 PMID: 25946284 http://www.nejm.org/doi/full/10.1056/NEJMcps1411346
  10. Kwit N et al Human Plague - United States, 2015 MMWR. August 25, 2015 / 64(Early Release);1-2 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0825a1.htm
  11. Harmon J, Kapitanyan R Poisoning Clues on the Skin: 10 Cases Medscape. April 6, 2017 http://reference.medscape.com/features/slideshow/acutepoisonings
  12. NEJM JWatch Editors. Arizona Fleas Test Positive for Plague Physician's First Watch, Aug 16,2017 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  13. Plague https://www.niaid.nih.gov/diseases-conditions/plague
  14. Centers for Disease Control and Prevention CDC Plague Home Page http://www.cdc.gov/ncidod/dvbid/plague/
  15. Wikipedia: Ring a Ring o' Roses https://en.wikipedia.org/wiki/Ring_a_Ring_o%27_Rosess