Septicemic plague

Primary pneumonic plague occurs after inhalation of organisms, which may occur by aerosol transmission from a person or animal with secondary or primary pneumonic plague. Septicemic plague may evolve from any form of plague. It features the acute onset of bacteremia, septic shock, and thrombosis with or without antecedent lymphadenitis. Prognosis for both pneumonic and septicemic pneumonic plague is poor the fatality rate is 100 percent for untreated cases. 

CLINICAL MANIFESTATIONS Bubonic Plague Septicemic Plague Pneumonic Plague Plague Meningitis Pharyngeal Plague Cutaneous Manifestations... 

Suggested Alternatives for Differential Diagnosis Plague and other septicemic diseases, acute pneumonia. 

Bubonic Plague Incubation period is from two to ten days. Malaise, high fever, and tender lymph nodes (buboes inflammatory swelling of one or more lymph nodes, usually in the groin the confluent mass of nodes usually suppurates and drains pus) may progress spontaneously to the septicemic form, with spread to the central nervous system (CNS), lungs, and elsewhere. 

Clinical Diagnosis A presumptive diagnosis can be made from by Gram or Wayson stain of lymph node aspirates, sputum, or cerebrospinal fluid. Plague can also be cultured. As for treatment, early administration of antibiotics is very effective. Supportive therapy for pneumonic and septicemic forms is required. 

Plagne remains a rare but reportable disease in the United States, with 390 cases reported from 1947 to 1996. Of these cases, 84% were bubonic, 13% septicemic, and 2% were pneumonic (23). Most hnman cases in the United States occur in two regions northern New Mexico, northern Arizona, and southern Colorado and California, southern Oregon, and far western Nevada (http //www.cdc.gov/ncidod/ dvbid/plague/epi.htm). Modes of transmission are known for 284 of 341 cases reported between 1970 and 1995 Flea bites were responsible for 222 (78%) cases, direct contact with an infected animal was responsible for 56 (20%) cases and inhalation of airborne materials snch as respiratory droplets from infected animals was responsible for 7 (2%) cases. Los Angeles was the site of the last person-to-person transmission in the United States in 1924 (23). 

May occur without bubo - termed primary septicemic plague http //www.argus I. com/ plague... 

Guarner J, Shieh WJ, Chu M, et al. Persistent Yersinia pestis antigens in ischemic tissues of a patient with septicemic plague. Hum Pathol. 2005 36 850-853. 

If the plague bacteria were to be dispersed in the air, a more likely scenario in a war or a terrorist attack, inhalation of such contaminated air can result in an outbreak of primary pneumonic plague. However, if the fleas in a less likely scenario were used to carry the plague organisms bubonic or the septicemic form of the disease can spread. 

Fig. 23-1. This Wright-Giemsa stain of a peripheral blood smear from a patient with septicemic plague demonstrates the bipolar, safety-pin staining of Yersinia pestis. Gram s and Wayson s stains can also demonstrate this pattern. Photomicrograph Courtesy of Ken Gage, Ph.D., Centers for Disease Control and Prevention, Fort Collins, Colo.

In the United States, 93% of cases have occurred between April and November, peaking in July. During the last 25 years, pneumonic plague accounted for 11% of cases, and bubonic or septicemic plague, or both, for 89%. One case of meningitic plague also occurred.45... 

In the United States, most patients (85%-90%) with human plague present clinically with the bubonic form, 10% to 15% with the primary septicemic form, and 1% with the pneumonic form. Sec-... 

Primary septicemic plague can occur from direct inoculation of bacilli into the bloodstream, bypassing initial multiplication in the lymph nodes. Asymptomatic pharyngeal carriage of plague has been reported to occur in contacts of patients with either bubonic or pneumonic plague.53,54... 

Fig. 23-9. This patient is recovering from bubonic plague that disseminated to the blood (septicemic form) and the lungs (pneumonic form). Note the dressing over the tracheostomy site. At one point, the patient s entire body was purpuric. Note the acral necrosis of (a) the patient s nose and fingers and (b) the toes. Photographs Courtesy Ken Gage, Ph.D., Centers of Disease Control and Prevention, Fort Collins, Colo.

Since 1948, streptomycin has remained the treatment of choice for bubonic, septicemic, and pneumonic plague. It should be given intramuscularly in a dose of 30 mg/kg/d in two divided doses. In cases of suspected meningitis or in patients who are hemodynamically unstable, intravenous chloramphenicol (50-75 mg/kg/d in four divided doses) should be added. Gentamicin has had much less clinical usage but can be used as an alternative to... 

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