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You are a pediatrician in an affluent suburban community. The mother of a 12-year-old boy brings him in for urgent evaluation. The youngster has been ill with fever, headache, and malaise for 4 days. His family has just returned from a two-week camping vacation in New Mexico. He appears wan and fatigued but is alert and oriented. Examination reveals fever and a slightly erythematous ear drum. You diagnose otitis media and initiate antibiotics. Two days later, his distraught mother calls saying that her son’s fever is worse, with relentless vomiting and severe abdominal pain. Suspecting appendicitis, the boy is referred to the ER. Surgery consultation is called for, and routine labs, including CBC, LFTs, and blood cultures are drawn. His WBC count is 25K with 60% bands, and he is taken to surgery. Intraoperatively, his appendix appears normal, but diffuse retroperitoneal and mesenteric lymphadenopathy is observed. He subsequently develops sepsis, ARDS, and DIC and is transferred to the ICU. In the ICU, he complains of severe headache and appears disoriented. His fingers are black, purpuric lesions are seen on his trunk and upper arms and Kernigs and Brudzinki’s signs are positive. That night, the lab calls stating that his blood cultures are growing gram-negative rods with a “safety pin” appearance. A rapid DFA sent to the State Health Department confirms Yersinia pestis.

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The first documented pandemic of Yersinia pestis occurred in 561 ad and is often called the Justinian Plague after the Holy Roman Emperor at the time. It began in Egypt and spread along trade routes killing upwards of 60% of the populations of Europe, North Africa, and southern and central Asia. The second great Yersinia outbreak, the so-called “Black Death,” occurred in 1346 and killed 25 million people, a third of the population of Europe (Fig. 15–1). Both pandemics were fueled by existing land and sea trade among countries in Europe, Asia, and Africa. The third pandemic began in China in 1855 and eventually spread worldwide. There continue to be intermittent outbreaks of plague throughout the world, although these outbreaks are isolated and better controlled primarily because of higher standards of living, improved sanitation and hygiene, and the availability of antibiotics.

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Figure 15–1
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Boccaccio’s Decameron—Depicting the Black Plague of 1348.

Courtesy of Brown University.

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Yersinia pestis is a nonmotile, non-spore-forming, gram-negative rod. Infection with Y. pestis tends to take one of three forms: bubonic, septicemic, and pneumonic. Historically the bubonic form of plague has been the most common. Classically, the disease is transmitted from infected rodents to humans by fleas residing on rats. As a biological weapon, pneumonic plague spread through aerosolization is expected to be the predominant form (Figs. 15–2 and 15–3).

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Figure 15–2
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Examination of rats suspected of carrying bubonic plague, New Orleans, ...

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