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  1. plague Dr: Rabie Zahran PUBLISHED BY more lectures

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  3. Plague Background . • The first pandemic was believed to have started in Africa and killed 100 million people over a span of 60 years. plague killed approximately one fourth of Europe's population. • The pandemic that began in China in the 1860s spread to Hong Kong in the 1890s and was subsequently spread by rats transported on ships to Africa, Asia, California, and port cities of South America. more lectures

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  6. Background • In the early twentieth century, plague epidemics accounted for about 10 million deaths in India. • Plague is worldwide in distribution, with most of the human cases reported from developing countries. more lectures

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  9. Epidemiology • A vector is anorganism that does not cause disease itself but that transmits infection by conveying pathogens from one host to another,[1] serving as a route of transmission. • Natural reservoir, refers to the long-term host of the pathogen of an infectious disease. It is often the case that hosts do not get the disease carried by the pathogen or it is carried as a subclinical infection and so asymptomatic and non-lethal. more lectures

  10. Causative organism. Yersiniapestis : • Non motile, non–spore-forming, pleomorphic, gram-negative cocco-bacillus. • The bacteria elaborate a lipopolysaccharide endotoxin, coagulase, and a fibrinolysin, which are the principal factors in the pathogenesis of this disease. more lectures

  11. Yersiniapestis : Yesinia is named in honor of Alexander Yersin, who successfully isolated the bacteria in 1894 during the pandemic that began in China in the 1860s. more lectures

  12. Reservoirs : • urban rats : • are the most important reservoirs for the plague bacillus, • but field mice, cats, camels, chipmunks, prairie dogs, rabbits, and squirrels can be important animal reservoirs as well. more lectures

  13. vector for transmission . Xenopsylla cheopis. • It is the rat flea, which is he most important vector for transmission of plague . • Ticks and human lice have been identified more lectures

  14. Pathophysiology • When a rat flea ingests a blood meal from an animal infected with Y pestis, the coagulase of the bacteria causes the blood to clot. The bacilli multiply in the blood clot, • the flea inoculates thousands of these bacilli into a host's skin during subsequent blood meals. • The bacilli migrate to the regional lymph nodes, are phagocytosed by the polymorphonuclear cells and mononuclear phagocytes, and multiply intracellularly. more lectures

  15. Pathophysiology • Involved lymph nodes show dense concentrations of plague bacilli, • destruction of the normal architecture, and medullary necrosis. With subsequent lysis of the phagocytes, • bacteremia can occur and may lead to invasion of distant organs in the absence of specific therapy. more lectures

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  17. Clinical • History : • Travel to endemic areas. • history of a flea bite, • close contact with a potential host, • exposure to dead rodents or rabbits should heighten consideration of a plague diagnosis. more lectures

  18. History :Bubonic plague • Patients most commonly present with this form of plague. • The incubation period varies but usually lasts 2-6 days. • Patients have a sudden onset of high fever, chills, and headache. • Patients also experience body aches, extreme exhaustion, weakness, abdominal pain, and/or diarrhea. • Painful, swollen lymph glands (buboes) arise, usually in the groin, axilla, or neck. more lectures

  19. History. Meningeal plague • Fever, headache, and nuchal rigidity • Buboes are common with meningeal plague. • Axillary buboes are associated with an increased incidence of the meningeal form. more lectures

  20. History. Pharyngeal plague • Pharyngeal plague results from ingestion of the plague bacilli. • Patients experience sore throat, fever, and painful cervical lymph nodes. more lectures

  21. History. Pneumonic plague • Pneumonic plague is highly contagious and transmitted by aerosol droplets. • Patients have an abrupt onset of fever and chills, accompanied by cough, chest pain, dyspnea, purulent sputum, or hemoptysis. • Buboes may or may not appear in pneumonic plague. more lectures

  22. History. Septicemic plague • Septicemic plague is observed in elderly patients and causes a rapid onset of symptoms. • Patients experience nausea, vomiting, abdominal pain, and diarrhea. (Diarrhea may be the predominant symptom.) • Patients exhibit a toxic appearance and soon become moribund. • Buboes are not observed with septicemic plague. • This form of plague is associated with a high mortality rate. more lectures

  23. Physical :Bubonic plague • Vesicles may be observed at the site of the infected flea bite. • With advanced disease  pustules, carbuncles, or papules may be observed in areas of the skin drained by the involved lymph nodes. • A generalized papular rash of the hands and feet may be observed. more lectures

  24. Physical :Bubonic plague • Buboes are unilateral, oval, extremely tender lymph nodes and can vary from 2-10 cm in size. Femoral lymph nodes are most commonly involved. • Hepatomegaly and splenomegaly often occur, causing tenderness. more lectures

  25. Physical • Pharyngeal plague : • causes pharyngeal erythema and painful and tender anterior cervical nodes. • Pneumonic plague : • causes fever, lymphadenopathy, productive sputum, or hemoptysis. more lectures

  26. Physical • Septicemic plague • toxic appearance tachycardia, tachypnea, and hypotension. Hypothermia is common. • Generalized purpura may be observed and can progress to necrosis and gangrene of the distal extremities. • No evidence of lymphadenitis or bubo formation is apparent. Patients may die from a high level of bacteremia. more lectures

  27. Septicemic plague • necrosis and gangrene of the distal extremities. more lectures

  28. Risk factors • Flea bite. • Contact with a patient or a potential host. • Contact with sick animals or rodents. • Residing in endemic areas of plague (eg, southwestern United States). • Presence of a food source for rodents in the immediate vicinity of the home. • Camping, hiking, hunting, or fishing. • Occupational exposure (eg, researchers, veterinarians) • Direct handling or inhalation of contaminated tissues or tissue fluids. more lectures

  29. Acute Renal FailurePharyngitis, BacterialAnthraxPneumonia, BacterialBrucellosisCatscratch DiseaseRocky Mountain Spotted FeverCellulitisSepsis, BacterialChancroidSeptic ShockDengue Fever SyphilisDisseminated Intravascular CoagulationLymphogranuloma Venereum (LGV) TularemiaLymphoma, B-CellTyphusMalaria Differential Diagnoses more lectures

  30. Laboratory Studies • Leucocytosis with a predominance of neutrophils is observed, Leukemoid reactions may be observed, more commonly in children. • Peripheral blood smear shows toxic granulations and Dohle bodies. • Thrombocytopenia is common, and levels of fibrin degradation products may be elevated. • Serum transaminase and bilirubin levels may be elevated. • Proteinuria may be present, and renal function test findings may be abnormal. • Hypoglycemia may be observed. more lectures

  31. Laboratory Studies • Blood culture results are often positive for Y pestis in patients with bubonic plague and septicemic plague. Y pestis may be observed on a peripheral blood smear. • Lymph node aspirates often demonstrate Y pestis. In patients with pharyngeal plague, Y pestis is cultured from throat swabs. • Cerebrospinal fluid (CSF) analysis in meningeal plague may show pleocytosis with a predominance of polymorphonuclear leukocytes. Gram stain of CSF may show plague bacilli. Limulus test of CSF demonstrates the presence of endotoxin. • Gram stain of sputum often reveals Y pestis. more lectures

  32. Imaging Studies • On chest x-ray films, patchy infiltrates, consolidation, or a persistent cavity is observed in patients with pneumonic plague. • ECG reveals sinus tachycardia and ST-T changes. • Obtain a CT scan of the head in a patient with altered mental status. • Nuclear imaging may help in localizing areas of lymphadenitis and meningeal inflammation. more lectures

  33. Other Tests • Direct immunofluorescence testing of fluid or cultures may aid in rapid diagnosis. • A passive hemagglutination test (performed on serum from a patient in acute or convalescent stages) with a 4-fold or greater increase in titer suggests plague infection. more lectures

  34. Procedures • Aspiration of lymph node (bubo) • Inject 1 mL of sterile saline into the bubo with a 20-gauge needle; after withdrawing several times, aspirate the fluid. Gram stain of the aspirate reveals gram-negative coccobacilli and polymorphonuclear leucocytes. • Wayson stain of the aspirate shows plague bacilli as light-blue bacilli with dark-blue polar bodies. • Examination of the aspirate of the fluid from the inguinal lymph nodes shows a characteristic bipolar appearance that resembles a closed safety pin. • Lumbar puncture for CSF analysis more lectures

  35. Treatment • Medical Care : • Precautions. • Place all patients thought to have plague and signs of pneumonia in strict respiratory isolation for 48-72 hours after starting antibiotic therapy. • Report patients thought to have plague to the local health department and to the World Health Organization. • Alert laboratory personnel to the possibility of the diagnosis of plague. All fluid specimens must be handled with gloves and mask to prevent aerosolization of the infected fluids. more lectures

  36. Treatment • Medical Care : • Supportive therapy • Hemodynamic monitoring and ventilatory support are performed as appropriate. • Intravenous fluids, epinephrine, and dopamine are necessary for correction of dehydration and hypotension. more lectures

  37. Treatment. • Surgical Care • Enlarging or fluctuant buboes require incision and drainage. • Consultations • Infectious disease specialists • Pulmonary and critical care specialists • General surgeons • Neurologists more lectures

  38. Medication : • Streptomycin sulfate : • is the preferred drug of choice to treat plague. • Dosing: • 30 mg/kg/day (up to a total of 2 g/day) in divided doses given IM, for a full course of 10 days of therapy or until 3 days after the temperature has returned to normal . more lectures

  39. Medication : • Doxycycline: • Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. • Dosing • Adult 100 mg PO/IV q12h • Pediatric • <8 years: Not recommended>8 years: 2-5 mg/kg/d PO/IV qd or divided bid; not to exceed 200 mg/d more lectures

  40. Medication : • Chloramphenicol : • Binds to 50S bacterial ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. • Dosing • Adult • 500 mg PO/IV q6h • Pediatric • 50-75 mg/kg/d PO/IV divided q6h more lectures

  41. Medication : • Aminoglycoside antibiotic recommended when less potentially hazardous therapeutic agents are ineffective or contraindicated. • Gentamicin : • Dosing • Adult • 2 mg/kg IV loading dose with normal renal function; then, 1.7 mg/kg IV q8h for 10 d. more lectures

  42. Medication : Fluoroquinolones : such as ciprofloxacin, have been shown to have good effect against Y. pestis in both in vitro and animal studies. Ciprofloxacin is bacteriocidal and has broad spectrum activity against most Gram-negative aerobic bacteria, more lectures

  43. Medication : • Sulfonamides : • The combination drug trimethoprim-sulfamethoxazole has been used both in treatment and prevention of plague. more lectures

  44. Prevention . • Prophylactic antibiotic therapy. • The CDC recommends administering prophylactic antibiotics for a short time to : • people who have been exposed to the bites of potentially infected rodent fleas during a plague outbreak. • personswho have handled an animal known to be infected with the plague bacterium. • personswho have had close exposure to a person or an animal thought to have pneumonic plague. more lectures

  45. Prevention . • Preferred antibiotics for prophylaxis against plague are : • Doxycycline 100 mg PO q12h for 14-21 days (for patients > 8 y) and trimethoprim 160 mg/ sulfamethoxazole 800 mg PO q12h for 14-21 days. more lectures

  46. Prevention . • Plague vaccine • Vaccination is of limited use and is not mandatory for entry into any country. • The vaccine is not effective against the pneumonic form of plague. • Plague vaccine is recommended for field workers in areas endemic for plague and for scientists and laboratory personnel who routinely work with the plague bacterium. more lectures

  47. Prevention . • Environmental sanitation • Remove food sources used by rodents. • Make homes, buildings, or warehouses "rodent-proof." • Trained professionals should apply chemicals to kill fleas and rodents. • Trained professionals should fumigate cargo areas of ships and docks. more lectures

  48. Complications. • Acute respiratory distress syndrome. • Chronic lymphedema from lymphatic scarring. • Disseminated intravascular coagulation • Septic shock. • Super infections of the buboes by Staphylococcus and Pseudomonas species more lectures

  49. Prognosis • Untreated patients with plague have a mortality rate of approximately 50%; however, with appropriate therapy, the mortality rate drops to approximately 5%. more lectures

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