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Bioterrorism

Bioterrorism

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Bioterrorism

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  1. Bioterrorism PLAGUE

  2. Learning Objectives • Describe epidemiologic features favoring a bioterrorism scenario with plague • Describe Y. pestis morphology • List isolation precautions required for patients suspected of having plague • List transmission routes for plague • Describe therapeutic options for patients with suspected plague

  3. Ancient roots…but still here http://www.cdc.gov/ncidod/dvbid/plague/epi.htm

  4. Case Presentation • You’re an ED physician practicing in Miami, FL. You’re tired because you were up late watching the presidential candidates’ debate before upcoming elections. • You just received sign-out from your colleague who is concerned about a previously healthy 37 yo male patient who presented with severe CAP. You pick up a chart from the rack and note that your next patient is a 36 yo female complaining of SOB. • You open the curtain and are immediately impressed by your new patient’s dyspnea and pallor. • The patient reports that she was well the day prior. She awoke this am with profound weakness, chills, and chest discomfort. Her cough progressed over the morning and noting blood in sputum, she came to the ED. ROS reveals some vague nausea and abdominal pain.

  5. Case presentation cont’d • PMH/PSH unremarkable and the patient has NKDA • Soc hx reveals an occasional smoker. She is in a monogamous relationship, and denies IV or inhaled illicit drug use. She has no recent travel outside the US, but is in town working on the debate team for one of the presidential candidates. • PE reveals a pale tachypneic female. HR 100 RR 28 BP 90/60 T 102.3 and pulse ox of 83% on RA. Lung exam with rhonchi and egophony in the left mid lung field. She is tachycardic without an appreciable murmur. Abdomen is mildly tender diffusely. She has no rash. • LABS: WBC 28 with 30%bands hgb 11.2 plt 450. BUN/Cr 18/1.3 • CXR shows…

  6. DDX • CAP (pneumococcus, legionella) • Anthrax • Influenza • ?SARS • ?PCP/HIV • Pulmonary embolism • ?Viral Hemorrhagic Fever

  7. Blood smear reveals:

  8. What is Plague? • Yersinia pestis: • gram-negative coccobacillus • Plague Syndromes • Bubonic • Pneumonic • Septicemic

  9. What is Plague? • Transmission: small rodent reservoir • BUBONIC • PNEUMONIC

  10. Naturally Occurring Bubonic - Isolated cases - SW United States - April-October and hunting season - Preceding rodent die-off Bioterrorism - Pneumonic (highly infectious) - Large clusters - Metropolitan cities No seasonality - Lack of rodent die off Epidemiology

  11. Pneumonic Plague-Primary • Incubation periods: 1-3 days • Clinical manifestations • Sudden onset fever, chills, HA, weakness, chest discomfort • Rapid progression pulmonary sx • Intense cough with thin sero-sang. Sputum • Radiology: • Lobar pneumonia, pleural effusion, ARDS

  12. Less common Plague syndromes • Plague pharyngitis • Similar to streptococcal or viral pharyngitis • Plague Meningitis • May be primary but usually occurs 1 week after septicemic or bubonic (↑axillary) • Often associated with delayed/static rx

  13. Laboratory diagnosis • Direct examination: sputum, blood, buboe aspirate • Gram stain, Giemsa or Wayson stain • gram negative coccobacillus • Bipolar staining • Cultures: positive within 24-48 hours

  14. Treatment • Aminoglycosides, Ciprofloxacin, Doxycycline, Chloramphenicol x 10days • Do NOT use cephalosporins

  15. Post exposure treatment and prophylaxis • The following patients require isolation and IV antibiotics: • All people with fever > 101 • All people with cough • Infants with tachypnea • Asymptomatic people within 2 meters of an untreated case should take PO antibiotics • Ciprofloxacin, Doxycycline for 7 days

  16. Vaccination • Vaccine is not currently available • Does not prevent or ameliorate primary pneumonic plague

  17. Infection Control • Isolation of patient until 48h of adequate rx • Droplet precautions • Surgical mask, gown, gloves, eye shield • Close contacts who refuse prophylaxis much be watched carefully x 7 days • Alert hospital personnel • Limit aerosol-generating procedures

  18. Plague Questions

  19. Question #1 In which of the following scenarios would you suspect bioterrorism? • Several pt with acute resp sx in NYC • Prairie-dog hunter with painful lump in armpit • Single patient with acute pneumonia and tender lymphadenopathy in N. Arizona

  20. Question #2 Sputum gram-stain will show: • Gram-positive diplococci • Gram-positive rods • Gram-negative coccobacilli • Gram-negative rods • Gram stain usually negative

  21. Question #3 Which of the following isolation measures is appropriate for a pt. with pneumonic plague? • N-95 mask, gown, gloves, goggles until anbx for 1 week • Surgical mask, gown, gloves, goggles until anbx for 1 week and clinically better • Surgical mask, gown, gloves, goggles until anbx for 48-72 hours and clinically better

  22. Question #4 Transmission of plague occurs via all of the following except: • Bite from a flea • Bite from a rodent • Cough from infected person within 2 meters • Standing water after a flood

  23. Question #5 Treatment options for a pt. with pneumonic plague include which list: • doxycycline, rifampin for 9 months • Doxycycline, Ciprofloxacin for 10 days • Aminoglycoside, Ceftriaxone for 60 days • Chloramphenicol, Ceftazidime for 7 days

  24. This completes the current presentation.