Terrorism WHAT CLINICIANS and NEED TO Disaster KNOW Pneumonic Plague errorism WHAT T CLINICIANS and NEED TO Disaster KNOW SERIES Uniformed Services University Guest Faculty EDITORS Health Sciences Ronald E. Goans, PhD, MD, MPH* Bethesda, Maryland Clinical Associate Professor Rush University Tulane University School of Public Health & David M. Benedek, MD, LTC, MC, USA Medical Center Tropical Medicine Associate Professor of Psychiatry Chicago, Illinois New Orleans, LA Stephanie R. Black, MD* Steven J. Durning, MD, Maj, USAF, MC* Sunita Hanjura, MD* Assistant Professor of Medicine Associate Professor of Medicine Rockville Internal Medicine Group Section of Infectious Diseases Rockville, MD Department of Internal Medicine Thomas A. Grieger, MD, CAPT, MC, USN* Associate Professor of Psychiatry Niranjan Kanesa-Thasan, MD, MTMH* Daniel Levin, MD* Associate Professor of Military & Director, Medical Affairs & Pharmacovigilance Assistant Professor Emergency Medicine Acambis General Psychiatry Residency Director Assistant Chair of Psychiatry for Graduate Cambridge, MA Department of Psychiatry & Continuing Education Jennifer C. Thompson, MD, MPH, FACP* Gillian S. Gibbs, MPH* Molly J. Hall, MD, Col, USAF, MC, FS* Chief, Department of Clinical Investigation Project Coordinator Assistant Chair & Associate Professor William Beaumont Army Medical Center Center of Excellence for Bioterrorism Department of Psychiatry El Paso, TX Preparedness Derrick Hamaoka, MD, Capt, USAF, MC, FS* Faculty Disclosure Policy Linnea S. Hauge, PhD* Director, Third Year Clerkship It is the policy of the Rush University Medical Educational Specialist Instructor of Psychiatry Department of General Surgery Center Office of Continuing Medical Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC* Education to ensure that its CME activities Associate Professor of Medicine are independent, free of commercial bias AUTHORS and beyond the control of persons or organi- Rush University Benjamin W. Jordan, MD, CDR, MC, USNR, FS* zations with an economic interest in influ- Assistant Professor of Psychiatry encing the content of CME. Everyone who Medical Center is in a position to control the content of an Chicago, Illinois James M. Madsen, MD, MPH, COL, MC-FS, USA* educational activity must disclose all relevant Stephanie R. Black, MD* Associate Professor of Preventive Medicine financial relationships with any commercial Assistant Professor of Medicine and Biometrics interest (including but not limited to pharma- Section of Infectious Diseases Scientific Advisor, Chemical Casualty Care ceutical companies, biomedical device manu- Department of Internal Medicine Division, US Army Medical Research Institute facturers, or other corporations whose prod- of Clinical Defense (USAMRICD), APG-EA ucts or services are related to the subject Daniel Levin, MD* matter of the presentation topic) within the Assistant Professor Deborah Omori, MD, MPH, FACP, COL, MC, USA* Associate Professor of Medicine preceding 12 months If there are relation- General Psychiatry Residency Director ships that create a conflict of interest, these Department of Psychiatry Michael J. Roy, MD, MPH, FACP, LTC, MC* must be resolved by the CME Course Associate Professor of Medicine Director in consultation with the Office of Director, Division of Internal Medicine Continuing Medical Education prior to the participation of the faculty member in the Jamie Waselenko, MD, FACP** development or presentation of course Assistant Professor of Medicine content. Assistant Chief, Hematology/Oncology Walter Reed Army Medical Center Washington, DC * Faculty member has nothing to disclose. **Faculty disclosure: CBCE Speaker’s Core for SuperGen. Pneumonic Plague CASE AUTHOR: Jennifer C. Thompson MD, MPH, FACP DISCLAIMER This project was funded by the Metropolitan Chicago Healthcare Council (MCHC) through a grant from the Health Resources and Services Administration (HRSA). The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as representing the opinion of Rush University Medical Center, the Department of the Army, Department of the Navy, Department of the Air Force, Department of Defense, MCHC or HRSA. FDA Approved Drug and Devices Assurance Statement In accordance with requirements of the FDA, the audience is advised that information pre- sented in this continuing medical education activity may contain references to unlabeled or unapproved uses of drugs or devices. Please refer to the FDA approved package insert for each drug/device for full prescribing/utilization information. INSTRUCTIONS The questions that appear throughout this case are intended as a self-assessment tool. For each question, select or provide the answer that you think is most appropriate and compare your answers to the key at the back of this booklet. The correct answer and a discussion of the answer choices are included in the answer key. In addition, a sign is provided in the back of this booklet for posting in your office or clinic. Complete the sign by adding your local health department’s phone number. Design and layout © 2005 Rush University Medical Center. The text contained herein falls under the U.S. Copyright Act of 1976 as a “U.S. Government Work” and is therefore considered Public Domain Information, however Rush University Medical Center reserves the right to copyright the design and layout of that information. 1 Pneumonic Plague CASE AUTHOR: Jennifer C. Thompson MD, MPH, FACP INTENDED AUDIENCE Internal medicine, family medicine, and emergency medicine physicians, and other clinicians who will provide evaluation and care in the aftermath of a terrorist attack or other public health disaster EDUCATIONAL OBJECTIVES Upon completion of this case, participants will be able to: • Describe the epidemiologic characteristics of plague that distinguish bioterrorist events from natural endemic outbreaks of disease. • Describe the clinical features of pneumonic, septicemic, and bubonic plague. • List the differential diagnoses of pneumonic plague and identify specimens and lab tests needed to confirm the diagnosis. • Discuss the ramifications of a plague outbreak including healthcare workers’ fear and absenteeism and depletion of healthcare teams. • Describe infection control precautions and recommendations for notifying infection control and the local health department. • Summarize basic treatment regimens, post-exposure prophylaxis, and management relevant to adult, pediatric, and pregnant patients with plague. CASE HISTORY A 29-year-old man from New Mexico was attending a professional conference in Washington, DC when he began experiencing abdominal pain, diarrhea, nausea, vomiting, and cough. He developed fever and chills and presented to a local primary care clinic. On evaluation he was febrile to 104˚F and orthostatic. The lung examina- tion was normal. The abdomen was soft and non-tender with slightly hyperactive bowel sounds. There was no lymphadenopathy. He was administered intravenous fluids and an anti-emetic for presumed gastroenteritis. COMMENT: The presence of cough may be a subtle clue that this was not a typical case of gas- troenteritis. However, it is easy to see how this symptom might have been missed or discounted in a busy acute care clinic. The challenge of diagnosing many agents of bioterrorism is that the initial signs and symptoms are often indistinguishable from common illnesses that are seen in day-to-day medical practice. Table 1 describes the 3 primary manifestations of plague and their associated differential diagnoses. 2 Table 1. Clinical Features of Plague Bubonic Pneumonic Septicemic Exposure Innoculation of bacteria from Hematogenous spread to lungs during Same as bubonic or pneumonic infected flea; exposure of abraded bacteremia associated with bubonic or plague skin to contaminated tissue septicemic plague; alternatively, primary pneumonic plague occurs after inhalation of bacteria during contact with person or animal with plague pneumonia Incubation 3-6 days 1-5 days 3-6 days Pathophysiology After inoculation, Y. pestis migrates Inhalation of aerosolized organisms Rapid progression results in release to regional lymph nodes where into the lungs results in foci of infection of organisms causing overwhelming aggressive intracellular multiplication bacteremia prior to the development occurs, resulting in enlargement, of lymphadenopathy; or enlarged inflammation and associated lymph nodes may be internal hemorrhage with necrosis (e.g. abdominal, mediastinal) and difficult to appreciate Primary Fever, malaise, focal lymphadenopathy Cough and hemoptysis, chest pain. Systemic toxicity with Y. pestis manifestations (1 – 10 cm), often in femoral or inguinal Chest radiographs may demonstrate bacteremia areas that becomes extremely tender infiltrates, cavities or consolidation Other May progress to sepsis syndrome Gastrointestinal symptoms e.g. nausea, DIC and acral necrosis may occur manifestations with disseminated intravascular vomiting, diarrhea, abdominal pain coagulation (DIC) may occur Differential Staphylococcal, streptococcal or Typical and atypical agents of Sepsis due to gram negative or gram diagnosis pasturella infections community acquired pneumonia positive agents, especially Tularemia (Francisella tularensis) meningococcemia, Cat scratch disease (Bartonella henselae) pneumococcal sepsis Chancroid (Haemophilus ducreyi) Lymphogranuloma venereum (Chlamydia trachomatis) Mononucleosis, CMV,Toxoplasmosis By the following morning the patient’s condition had deteriorated,