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PLAGUE AND ITS CURE
Saddam Hussein has been
producing plague germ stockpiles
in Iraq as well as in a plant in Sudan he
built for the
Sudanese Fanatical Muslim Government.
This IS one
disease we must prepare for.
plague, pneumonic plague)
What is plague?
is a serious illness caused by bacteria called Yersinia pestis. The disease is
carried by rodents (i.e., rats and mice) and their fleas, which can then transmit
the disease to humans as well as to other animals. Plague is very rare in the
United States, but cases are still reported in the southwestern states of New
Mexico, Arizona, Colorado, Nevada, and California. The most common form of plague
is bubonic plague which affects the body's lymph nodes. When the infection involves
the lungs, the disease is called pneumonic plague.
How do you get
You can get plague from the bite of infected fleas or by a scratch
or bite while handling infected animals. You can also get it by breathing in airborne
droplets from people who have the plague infection in their lungs or from infected
Editor: Balaam's Ass Speaks-- The
problem in germ warfare is that the plague is distributed on the wind and inhaled.
This gets it into the blood and lungs, and the progress of the disease is
more rapid. Thus, the drug cures must be ON HAND, and they must be started at
once as symptoms appear.
What are the symptoms of plague?
The first symptoms of bubonic plague include the sudden onset of fever with painful
swelling of the lymph nodes, called bubos in the areas closest to the flea bite
(typically, in the groin, armpit, or neck). Chills, muscle-aches, weakness, fatigue,
nausea, and headache may also occur. If the infection spreads to the lungs, it
produces pneumonia that is highly contagious and often, fata. Pneumonic plague
is characterized by fever, swelling of the lymph nodes, cough, chest pain, and
frequently, blood in the saliva.
When do symptoms start?
The symptoms of plague begin 1 to 7 days following the bite of an infected flea.
What is the treatment for plague?
Antibiotics can be prescribed
by a doctor to treat plague. It is extremely important to detect and treat the
disease early in its course. If left untreated, about half of those with bubonic
plague will die. Prompt treatment can reduce the case fatality to less than 5%.
Persons who are infected with pneumonic plague should be quarantined for 3 full
days of medical therapy.
How do you keep from getting it?
Avoid rat-infested areas if possible. If you go to areas where plague is endemic
(an ongoing problem), take precautions to protect yourself against rodents and
Avoid contact with sick or dead animals found on the
roadside or in the woods. The risk of being bitten by infected fleas is high when
plague infection kills large numbers of rodents. The infected and starving fleas
aggressively look for new hosts.
Carefully supervise the activities
of all children and household pets (i.e., dogs and cats) when outdoors in forest/picnic
areas where rodents make their nests.
International travelers to a
plague-endemic area (areas reported to have an ongoing plague problem) are generally
at low risk for infection for Y. pestis. If you are travelling to a plague endemic
area call your doctor or the Health Department for advice.
all suspected plague cases promptly to your doctor or to the Department of Health.
"Return to Navigating the Communicable Diseases - Table of Contents"
I OFFER A SECOND AND RATHER INTERSETING PRESENTATION:
Authored by Demetres Velendzas, MD, Emergency Medicine, Department of Traumatology
& Emergency Medicine, University of Connecticut Health Center and Susan Dufel,
MD, FACEP, Residency Director, Associate Professor of Emergency Medicine, Department
of Traumatology & Emergency Medicine, University of Connecticut Medical Center
plague has caused more fear and terror than perhaps any other infectious disease
in the history of mankind. It has laid claim to nearly 200 million lives and has
brought about monumental changes such as the end of the Dark Ages and the advancement
of clinical research in medicine. Although it is still debated by historians,
the plague has been responsible for three great pandemics in history. The first
spread from the Middle East to the Mediteranean basin during the 5th and 6th century
AD, killing approximately 50% of the population in these areas.
second pandemic afflicted Europe between the 8th and 14th century wiping out nearly
40% of the population of Europe. The 3rd pandemic started around 1855 in China
and spread to every major continent. It was during this pandemic in 1894 that
Alexandre Yersin isolated the plague bacillus, developed an antiserum to combat
the disease, and postulated its connnection with fleas and rats.
plague bacillus was named Yersinia Pestis in his commemoration. These pandemics
have suceeded in entrenching the plague in every major continent, with the possible
exception of Australia. Unlike smallpox, the plague will never be eradicated.
It lives in millions of animals and on billions of fleas that reside on them.
It is a disease of the desert, the steppes, the mountain, and the forest. The
epidemic in India in October of 1994, which affected nearly 600,000 residents,
is a reminder of the ease with which the plague can escape medical control.
The exact pathophysiology
of the plague is unknown. The etiologic agent is Yersinia Pestis, an aerobic,
facultatively anaerobic, intracellular gram negative bacillus. The organism
can be transmitted from a host to a human via the bite of a vector. There are
more than 200 different rodents and species that can serve as hosts. These include
domestic cats, dogs, squirrels, chipmunks, marmots, deer mice, rabbits, hares,
rock squirrels, camels, and sheep.
The vector is usually the rat flea,
Xenopsylla Cheopis. Thirty different species have been identified as able to carry
the plague bacillus, however, including ticks and human louses. Rodents that are
resistant to the infection form an enzootic stage that assures the long term survival
of the bacillus. Occasionally, the infected animals are not resistant to the disease
and die. This is known as an epizootic stage and it ensures the spread of the
organism to new territory. A sylvatic stage occurs when humans are infected from
wild animals. Transmission is not only vector mediated, but may occur via inhalation
of aerosilized bacilli or close contact with infected tissue
The bacillus proliferates in the fleas esophagus preventing
food entry into the stomach. To overcome starvation, the flea begins a blood sucking
rampage. Between its attempts to swallow, the distended bacillus - packed esophagus
recoils, depositing the bacillus into the victims skin. The bacillus invades nearby
lymphoid tissue producing the famous bubo - an inflamed, necrotic, and hemorrhagic
Spread occurs along the lymphatic channels towards the
thoracic duct with the eventual seeding of the vasculature. Bacteremia and septicemia
ensue. The bacillus potentially seeds every organ including the lungs, liver,
spleen, kidney, and rarely the meninges. Direct inhalation of the bacillus results
in pneumonic plague and subsequent bacteremia and septicemia. The bacillus causes
a multilobar hemorrhagic and necrotizing bronchopneumonia.
type of plague is primary septicemic plague. It is hypothesized that this occurs
when the bacillus is deposited early in the vasculature bypassing the lymphatics.
There is early dissemination with sepsis without the formation of a bubo. This
is usually seen in bites to the oral, tonsillar, and pharyngeal area and is believed
to occur because of the short lymphatic distance to the thoracic duct.
In the U.S.: An average of 18 cases per year
have been reported during the last few decades. The prairie dog repopulation of
the southwestern plains that had been depleted by an epizootic stage is nearly
complete. There is some evidence to suggest that a new epizootic stage is begining
with higher sylvatic infections being reported since 1992. West of the 100th parallel,
in states like New Mexico, Arizona, Colorado, Utah, and California there exists
one of the largest animal foci of the plague worldwide. It is of note that only
one case of imported plague has been reported since 1926.
Between 1967 and 1993 there have been annually an average of 1,666 cases of the
plague reported by the World Health Organization. The number of actual cases is
probably much higher given the failure of many countries to diagnose and report
the plague. In decreasing order the following countries reported the most cases
of the plague since 1979: Tanzania, Vietnam, Zaire, Peru, Madagascar, Burma, Brazil,
Uganda, China, and the United States.
Bubonic Plague has 1-15% mortality in treated cases and a
40 - 60% mortality in untreated cases. Septicemic plague (either primary
or secondary) has 40% mortality in treated cases and a 100% mortality in untreated
cases. Pneumonic plague (either primary or secondary) has a 100% mortality
if not treated within the first 24 hours of infection.
Greater than 50% of cases occur in males.
Approximately 50% of cases occur in persons less
than 20 years of age.
travel in the southwestern and pacific coast regions of the United States, particularly
in New Mexico, Arizona, California, and Utah should raise suspicion of a flea
bite. Although imported plague is rare, similar suspicion should exist for any
recent travel in endemic areas outside the US.
Close contact with
any potentially infected host or rural environment should raise suspicion for
the plague. Although historically the rat has been thought to be the main plague
host, currently in the United States, the ground and rock squirrel are the most
common hosts. It is also noteworthy that in recent years the domestic cat has
emerged as a prominent host that transmits the plague to veterinarians.
Fever, chills, body aches, sore throat, headache, and weakness.
painful, swollen "node"
Abdominal pain, nausea, vomiting (bloody at
times), constipation or diarrhea, black or tarry stools. It is noteworthy that
gastrointestinal complaints may precede the development of a bubo.
Cough which may be productive of bloody sputum.
Shortness of breath
Stiff neck (if meningitic infiltration by the plague bacillus has
of 37 - 40.9 C, tachycardia, tachypnea, hypotension if in late septic shock.
Inguinal bubo (60%), axillary bubo (30%), cervical (10%), or epitrochlear
(10%). Bubo's are usually no greater than 5 cm, extremely tender and erythematous,
and surrounded by a boggy hemorrhagic area.
At the site of the flea
bite there may be a maculo - papular lesion. Other dermatologic findings include
vesicles, pustules, skin cyanosis of extremites (digits, penis, nares), ecchymosis,
and petechiae (from DIC). It is thought the name "black death" originated because
of the (black) cyanotic color of the necrotic limbs of infected individuals.
Diffuse crackles, diffuse areas of dullness to percussion (secondary to
the patchy consolidation of pneumonic plague), hemoptysis
abdominal tenderness, with or without guarding, splenomegaly, hematochezia or
heme positive stools
Nuchal rigidity, diffuse muscle and joint tenderness
Various degrees of mental status changes, ranging from mild confusion
or agitation to delirium and coma
from any body site or cavity, ie. hematemesis, hematochezia, hemoptysis.
Gangrene and necrosis of areas like the digits, penis, nares. (This is
a phenomenon ascribed to peripheral thrombosis secondary to DIC and cyanosis)
Crystalloid infusion to maintain
normal vital signs and clinical hydration state.
via nasal cannula, non - rebreather mask, or intubation, as determined by the
distress of the patient. Pulse oximetry can be used to
monitor the degree of respiratory compromise.
Health care personel should assume universal
precautions when dealing with any patient with an infectious diseasepresentation.
This should include goggles, gloves, and gown. If respiratory symptoms are present
masks should be worn.
Emergency Department Care:
Depending on the stage of presentation
supportive care will vary. Early presentation may only require crystalloid administration
with monitoring of vital signs, clinical state, and urine output. Septic shock
would require invasive hemodynamic monitoring with crystalloid and vasopressor
agents. Airway managment may require intubation and mechanical ventilation with
Empiric Antibiotic Coverage (see next section)
If respiratory symptoms are present universal
precautions must be instituted with strict respiratory isolation for the first
72 hours of therapy. If no respiratory symptoms are present only 48 hours of isolation
are needed or until there is no purulent drainage by the bubo. All contaminated
material should be incinerated or autoclaved.
Infectious Disease Specialist
of the Centers For Disease Control will allow samples to be sent to the headquarters
in Colorado for diagnosis by fluorscent antibody testing. In addition, the CDC
in conjunction with the Department of Health will attempt to identify the source
of the plague and implement early epidemiologic control measures to control a
In most cases
of the plague some degree of septic shock will be present. Invasive hemodynamic
monitoring and close observation of fluid and cardiac status will require admission
to a Medical Intensive Care Unit.
Medical management of the Plague can involve a myraid of supportive medications,
including crystalloids, colloids, medications used for intubation, vasopressor
agents, antiulcer, and antipyretic agents. This section will only cover the antibiotic
management of the plague. It is essential that antibiotics be given early, after
samples for diagnostic purposes have been obtained.
Category: Antibiotics - Drugs that cover Y. Pestis should be empirically given
to any patient with predisposing risk factors, signs and symptoms of the plague.
Drug Name: Streptomycin - Streptomycin is the drug of choice
in combination with tetracycline or chloramphenicol. Because of the drugs toxicity
it is usually discontinued after the first five days of treatment and tetracycline
(or chloramphenicol) is continued alone for the remaining course. Streptomycin
is a class D antibiotic for pregnancy. Given the high mortality of the plague,
however, streptomycin and chlorapmhenical are the antibiotics of choice for the
treatment of the plague in a pregnant patient.
Adult Dose: 30mg/kg/day
IM divided either bid,tid,or qid Maximum daily dose 2g
20-30mg/kg/day IM divided either bid, tid, or qid
Note - newborn infants
with transplacental infection by the plague should receive gentamycin instead.
Contraindications: Contraindicated in a documented aminoglyside hypersensitivity
Interactions: Synergistic toxicity with other ototoxic,nephrotoxic
and peripheral neuromuscula
Pregnancy: D - Unsafe in pregnancy
Precautions: Impaired renal funtion ( may need dose adjustment)
Tetracycline (Sumycin, Tetracyn IV):
Drug of choice for use with streptomycin for the first five days of treatment
(or until the patient is afebrile) and alone for the remaining course.(Marcus
Adult Dose: 15mg/kg (maximum 1g) po loading dose; 40-50mg/kg
po q4 hours day 1; 30mg/kg po q 6hours for a total of 10 - 14 days of therapy;
if oral therapy not tolerated may give IV 5mg/kg iv loading dose; 15mg/kg iv q4hours
day 1; 5mg/kg iv q6hours for the remainding treatment; May switch to po at any
time if patient can tolerate it.
Pedistric Dose: If the suspicion
of the plague is high some authors recommend similar dosages and regimens for
all pediatric cases, even children less than 8 years old.
Pregnancy, Children less than 8 years of age
nephrotoxic and hepatoxic drugs.
Pregnancy: D - Unsafe in pregnancy
Precautions: Renal insufficiency, liver disease, use with dairy products
and Fe salts
Drug Name: Chloramphenicol
(chloromycetin) - Drug of choice to be used instead of tetracycline, in plague
meningitis (better CNS penetrations), profound hypotension, pleural or pericardial
involvement, and in the pregnant patient.
Adult Dose: 50 - 100 mg/kg/qd
iv divided q6hours; 30 mg/kg/qd po divided q6 hours may be substituted instead
of iv for the last 5 days of therapy
Pediatric: Infant 0-7 days
25 mg/kg po or iv qd; Infant >7 days 50 mg/kg/qd po or iv divided q12 hours
Contraindications: No absolute contraindications. Careful in
pregnancy, with breast- feeding, hepa
Interactions: May increase
effects of warfarin, phenytoin, chlorpropamide, and tolbutamide
C - Safety for use during pregnancy has not been established
Precautions: May cause anemia, aplastic anemia, childhood leukemia,
and grey - baby syndrome
Category: Prophylactic antibiotics - This is how to take the drug if Plague is
in the area or you know a terrorist release of the toxin has taken l\place where
you were present.
[ Editor: Balaam's Ass Speaks--
If the plague is active in your area in epidemic proportions, I suggest
you take one 500 mg of Tetracycline a day, on an empty stomach, as a
All contacts with the bubonic or septicemic plague
should be placed under surveillance. At first sign of illness (fever, adenopathy,
etc.) regular antibiotic treatment should be started. Household contacts of patients
with the bubonic or septicemic plague may have been exposed to the same fleas
so antibiotic prophylaxis is recommended. Prophylaxis is also indicated for all
contacts with patients with the pneumonic plague, ie. emergency department and
Drug Name: Tetracycline - DOC in adults and children
greater than 8 years of age.
Adult Dose: 25 - 50 mg/kg/day po
Pediatric: 250 mg po qid for 5-10 days
Contraindications: pregnancy, children less than 8 years of age,
Dairy products and Fe salts may reduce GI absorption.
D - Unsafe in pregnancy
Precautions: May increase azotemia
in patients with prior renal insufficiency.
Editor: Balaam's Ass Speaks-- The doctor
has to tell you that the drugs are a problem for pregnant women. If you
know a lady you live has become infected with the plague, you will want to do
one of the following:
1. Contact a doctor and see if you can
get medical help for the lady.
IF THAT CANNOT BE DONE DUE TO CHAOS:
2. Start the course and take the risk. The lady will certainly
die if she was infected by breathing in the toxin, and if you do nothing. You
should be aware that the baby could be born with problems though.
Cure of choice if you have no opportunity to follow the details above- Tetracycline--
Double the first two day's doses and then follow normal dosing. 600 mg a
day on empty stomach circa two hours after a meal. Exception is Doxyciline
and Minocycline which can be taken with food. 40 pills of 500 to 600 mg
each should be taken over a maximum of a 10 day period. The Dr. in Mexico
suggested 500 mg every 6 to 8 hours.
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