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For further information, see CMDT Part 35-25: Plague

KEY FEATURES

Essentials of Diagnosis

  • History of exposure to rodents in endemic area

  • Sudden onset of high fever, muscular pains, and prostration

  • Axillary, cervical, or inguinal lymphadenitis (bubo)

  • Pustule or ulcer at inoculation site

  • Pneumonia or meningitis may be fatal

  • Positive smear and culture from bubo and positive blood culture

General Considerations

  • A zoonotic infection carried by wild rodents and caused by Yersinia pestis, a small bipolar-staining gram-negative rod

  • It is transmitted among rodents and to humans by the bites of fleas or from contact with infected animals

  • Following the flea bite, the organisms spread through the lymphatics to the lymph nodes, which become greatly enlarged (buboes). They may then reach the bloodstream to involve all organs

  • If pneumonia develops in a patient with plague, the infection can be transmitted by droplets to other individuals

  • The incubation period is 2–10 days

  • Because of its extreme virulence, its potential for dissemination and person-to-person transmission, and efforts to develop the organism as an agent of biowarfare, plague bacillus is considered a high-priority agent for bioterrorism

Demographics

  • Most human cases in the United States occur in California, Arizona, Nevada, Oregon, Colorado, and New Mexico

  • Globally, countries with the greatest number of cases include the Democratic Republic of the Congo, Madagascar, and Peru

CLINICAL FINDINGS

Symptoms and Signs

  • The onset is sudden, with

    • High fever

    • Malaise

    • Tachycardia

    • Intense headache

    • Delirium

    • Severe myalgias

  • A pustule or ulcer may be observed at the site of inoculation

  • Axillary, inguinal, or cervical lymph nodes become enlarged and tender and may suppurate and drain

  • Signs of meningitis may develop

  • With hematogenous spread, the patient may rapidly become toxic and comatose, with purpuric spots (black plague) appearing on the skin

  • Primary pneumonic plague is a fulminant pneumonitis with bloody, frothy sputum and sepsis

  • If pneumonia develops, tachypnea, productive cough, blood-tinged sputum, and cyanosis also occur

Differential Diagnosis

  • Lymphadenitis accompanying staphylococcal or streptococcal infections of an extremity

  • Sexually transmitted diseases, such as lymphogranuloma venereum or syphilis

  • Tularemia

  • Enteric or rickettsial fevers

  • Malaria

  • Influenza

  • Other bacterial pneumonias

  • Meningitis caused by other bacteria

DIAGNOSIS

Laboratory Studies

  • The plague bacillus may be found in Gram-stained smears from aspirates of buboes

  • Cultures from bubo aspirate or pus, blood, cerebrospinal fluid, and sputum can be positive but may grow slowly

  • In convalescing patients, an antibody titer rise may be demonstrated by agglutination tests

TREATMENT

Medications

  • Therapy should be started immediately once plague is suspected

    • Either a fluoroquinolone (ciprofloxacin, 400 mg intravenously every 8 hours or 750 mg orally ...

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