1. Bioterrorism Agents – Plague Lesson 2 Clinical Presentation

2. Objectives Identify distinctions betweenIdentify distinctions between –Bubonic Plague –Pneumonic Plague –Septicemic Plague

3. Bubonic Plague Incubation: 2 to 6 daysIncubation: 2 to 6 days SymptomsSymptoms –Lymphadenopathy, fever –Buboes at site of inoculation Disease Progression - UntreatedDisease Progression - Untreated –Septicemia –Secondary Pneumonic Plague –Meningitis (rare)

4. Bubonic Plague

7. Pneumonic Plague Incubation: 2 to 4 days (range 1 to 6 days)Incubation: 2 to 4 days (range 1 to 6 days) SymptomsSymptoms –Acute fever, chills, malaise, myalgias –Productive cough –Watery mucoid sputum, may be bloody –Associated chest pain, increasing dyspnea

8. Pneumonic Plague Disease ProgressionDisease Progression –Adult Respiratory Distress Syndrome –Refractory pulmonary edema –Signs of shock –Without treatment in less than 24 hours, almost universally fatal

9. Pneumonic Plague Coughing patient can spreadCoughing patient can spread Respiratory precautionsRespiratory precautions Rapidly expanding infiltratesRapidly expanding infiltrates Pulmonary parenchymal necrosis and hemorrhagePulmonary parenchymal necrosis and hemorrhage Occasional pulmonary abscessesOccasional pulmonary abscesses Enlarged hilar nodes and pleural effusionsEnlarged hilar nodes and pleural effusions

10. Pneumonic Plague

13. Septicemic Plague Incubation: Most common as complication of pneumonic or bubonic plagueIncubation: Most common as complication of pneumonic or bubonic plague SymptomsSymptoms –Acute fever, chills, prostration, abdominal pain, nausea, vomiting Disease ProgressionDisease Progression –Purpura –DIC –Hypotension and other signs of shock –Fatal if not treated

14. Other Plague Presentations Pharyngeal PlaguePharyngeal Plague –Uncommon –Resembles tonsillitis with peritonsillar abcess –Cervical lymphadenopathy Plague MeningitisPlague Meningitis –Most common in children –Usually end result of ineffective treatment of other forms –Symptoms mimic other forms of acute plague

15. Infection Control Large numbers of plague bacilliLarge numbers of plague bacilli Respiratory droplet spread in close direct contactRespiratory droplet spread in close direct contact Respiratory droplet precautions with suspect casesRespiratory droplet precautions with suspect cases Contact public healthContact public health

16. Review Questions Plague Lesson 2

17. Plague Review Questions Lesson 2, Question 1 Gary, Indiana hospitalGary, Indiana hospital 12 month old from Gary12 month old from Gary Acute onset fever, malaise, body aches x 2 daysAcute onset fever, malaise, body aches x 2 days Extremely tender lymph node under arm, 2 inchesExtremely tender lymph node under arm, 2 inches Exhibiting neurologic symptomsExhibiting neurologic symptoms Suspect plague meningitis. First step?

18. Plague Review Questions Lesson 2, Question 1 What is your first step? A.Call local health department B.Rule out other diseases C.Place in isolation

19. Plague Review Questions Lesson 2, Question 1 What is your first step? A. Call your local health department

20. Plague Review Questions Lesson 2, Question 2 Patient presents after 24 hours with no treatmentPatient presents after 24 hours with no treatment How would you expect the patient to progress?

21. Plague Review Questions Lesson 2, Question 2 How would you expect the patient to progress? A.It should resolve on its own B.Septicemia, pneumonia, meningitis C.Entire appendage involved. Amputation. D.Kidney failure

22. Plague Review Question Lesson 2, Question 2 How would you expect an untreated patient to progress? B. Septicemia, pneumonia, meningitis

23. A. The best choice is B…. B. Correct. Adult respiratory distress syndrome (ARDS) characterized by refractory pulmonary edema may occur. Signs of shock including hypotension and eventual multi- organ failure may also occur. Without early detection and treatment in less than 24 hours, pneumonic plague is almost universally fatal. C. The best choice is B… D. The best choice is B… Module: Plague BT Agents BT Agents Home 3) You have a patient who you suspect has pneumonic plague. What is likely to happen if treatment is not offered within 24 hours? B. Without treatment within 24 hours, pneumonic plague is almost always fatal. C. It will progress to the bloodstream and cause septicemic plague. D. There is no progression of disease in cases of bubonic plague. Next Back 9 of _ Plague: Lesson 2- Clinical Presentation Module Introduction- Module Objectives Target Audience Continuing Education Credit Lessons- 1) General OverviewGeneral Overview 2) Clinical Presentation 3) Differential DiagnosisDifferential Diagnosis 4) Laboratory IssuesLaboratory Issues 5) Medical ManagementMedical Management 6) Public Health IssuesPublic Health Issues 7) Veterinarian IssuesVeterinarian Issues 8) Module Self-Assessment Additional ResourcesModule Self-AssessmentAdditional Resources A. Once plague has progressed to the pneumonic form, it is too late for treatment to be offered. Do you want to review?

24. Plague Review Questions Lesson 2, Question 3 Suspect pneumonic plagueSuspect pneumonic plague What will happen without treatment in 24 hours?

25. Plague Review Questions Lesson 2, Question 3 What will happen without treatment in 24 hours? A.It’s too late for treatment B.Almost always fatal C.Septicemia D.No progression

26. Plague Review Questions Lesson 2, Question 3 What will happen without treatment in 24 hours? B. Almost always fatal