Bioterrorism Agents Plague Lesson 3 Differential Diagnosis Objectives
Bioterrorism Agents – Plague Lesson 3 Differential Diagnosis
Objectives • List the diseases that should be considered in the differential diagnosis of plague • Describe how to rule out other diseases when diagnosing plague
Bubonic Plague • Incubation: 2 to 6 days • Symptoms – Chills, high fever – Swollen and painful lymph nodes in groin, thigh, underarm and/or neck – Buboes at site of inoculation – Lymph nodes not hot, skin smooth and red – Rapid pulse – Hypotension
Bubonic Plague • Disease Progression – Septicemia – Pneumonic Plague – Meningitis (rare) • Other Symptoms – Restlessness, confusion, lack of coordination – Intestinal discomfort – Lymph nodes may suppurate second week
Bubonic Plague Differential Diagnosis • • Capnocytophaga canimorsus Cellulitis Lymphogranuloma venereum Non-specific infections Lymphogranuloma venereum
Bubonic Plague Differential Diagnosis Streptococcal or staphylococcal adenitis (Staphylococcal aureus, Staphylococcal pyogenes) Tularemia (Francisella tularensis) Cat scratch disease (B. henselae) © 2003 CIDRAP/IDSA • Purulent/ inflamed lesion often distal to nodes • Involved nodes more likely to be fluctuant • Ascending lymphangitis or cellulitis may be present • Ulcer or pustule distal to nodes • Rarely as fulminant as in plague • Systemic toxicity uncommon • History of cat contact/scratch • Indolent clinical course • Primary lesion at site of scratch • No systemic toxicity
Bubonic Plague Differential Diagnosis Mycobacterial infection, • Adenitis occurs in cervical region including scrofula • Usually painless (Mycobacterium • Indolent clinical course tuberculosis and other • More likely to occur in immunocompromised Mycobacterium species) patients Lymphogranuloma venereum (Chlamydia trachomatis) © 2003 CIDRAP/IDSA • Adenitis occurs in the inguinal region • Sexual exposure 10 -30 days previously • Suppuration, fistula tracts common • Exquisite tenderness usually absent • Although patients may appear ill (headache, fever, myalgias), systemic toxicity not present
Bubonic Plague Differential Diagnosis Chancroid • Adenitis occurs in inguinal region (Hemophilus ducreyi) • Ulcerative lesion present • Systemic symptoms uncommon; toxicity does not occur • Genital area • Adenitis occurs in the inguinal region • Severe systemic toxicity not present Primary genital herpes Primary or secondary syphilis (Treponema pallidum) • • • Strangulated inguinal hernias • Evidence of bowel involvement © 2003 CIDRAP/IDSA Enlarged lymph nodes in inguinal region Lymph nodes generally painless Chancre may be noted
Pneumonic Plague • Incubation: 2 to 4 days (Range: 1 -6 days) • Symptoms – Fever, chills, malaise, myalgias – Productive cough, watery mucoid – Chest pain, dyspnea – Hemoptysis – Gastrointestinal – Cervical Bubo (rare)
Pneumonic Plague • • • Rapidly progressive Respiratory failure within 2 to 4 days Chest X-Rays – bilateral patchy infiltrates Shock, hypotension, multi-organ failure Treat within 24 hours or almost universally fatal
Pneumonic Plague
Primary Pneumonic Plague Outbreak Diagnoses • Presumptive; especially if associated • Rule out other causes – Severe pneumonia – Rapidly progressive respiratory infection – With or without sepsis
Primary Pneumonic Plague Differential Diagnosis • • • Inhalational anthrax Tularemia Community-acquired bacterial pneumonia Viral pneumonia Q fever Anthrax
Primary Pneumonic Plague Differential Diagnosis Inhalational anthrax (Bacillus anthracis) Tularemia (Francisella tularensis) © 2003 CIDRAP/IDSA • Widened mediastinum and pleural effusions • Not true pneumonia • Minimal sputum production • Hemoptysis uncommon Not as rapid or fulminant as in pneumonic plague
Primary Pneumonic Plague Differential Diagnosis Community-acquired bacterial pneumonia • Mycoplasmal pneumonia (Mycoplasma pneumoniae) • Pneumonia caused by Chlamydia pneumoniae • Legionnaires' disease (Legionella pneumophila or other Legionella species) • Psittacosis (Chlamydia psittaci) • Other bacterial agents (e. g. , Staphyloccocus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella catarrhalis) © 2003 CIDRAP/IDSA • Rarely as fulminant • Usually occur in persons with underlying pulmonary or other disease or in the elderly • Bird exposure with psittacosis • Gram stain may be useful • Community outbreaks not as explosive as pneumonic plague outbreak • S. pneumoniae usually institutional • Community outbreaks of Legionnaires' disease often involve exposure to cooling systems
Primary Pneumonic Plague Differential Diagnosis Viral pneumonia • • Influenza Hantavirus RSV CMV Q fever (Coxiella burnetii) © 2003 CIDRAP/IDSA • Influenza generally seasonal • History of recent cruise ship travel or travel to tropics • Exposure to excrement of mice with Hantavirus • RSV usually occurs in children • CMV usually occurs in immunocompromised patients • Exposure to infected parturient cats, cattle, sheep, goats • Severe pneumonia not prominent
Septicemic Plague • Incubation: Most common as complication • Symptoms – Fever, chills, prostration – Gastrointestinal • Disease Progression – Pupura – DIC – Amputation Pupura
Septicemic Plague Differential Diagnosis Meningococcemia Evidence of meningitis Septicemia caused by other gram- Underlying illness usually present negative bacteria © 2003 CIDRAP/IDSA
Review Questions Plague Lesson 3
Plague Review Question Lesson 3, Question 1 • • 36 yo, F, Chicago, IL Housekeeper No hx of travel, animal exposure Symptoms – Severe abdominal pain – Productive cough – Shortness of breath
Plague Review Question Lesson 3, Question 1 • Exam Findings – Productive cough, thick, bloody sputum – Bilateral rales – Little-to-no air movement lower left lung field – Chest X-Ray – bilateral infiltrates – CSF – Cloudy – Temperature – 102. 3 F – Pulse rapid and thready – Liver not enlarged, no enlarged lymph nodes What diagnoses would you rule out?
Plague Review Question Lesson 3, Question 1 What diagnoses would you rule out? A. B. C. D. Anthrax Tularemia Pneumonic Plague Bubonic Plague
Plague Review Question Lesson 3, Question 1 What diagnoses would you rule out? C. Pneumonic Plague
Plague Review Question Lesson 3, Question 2 • • 32 yo, M, Philadelphia, PA Computer Programmer No hx travel, Healthy dog Symptoms – Headache, chills, fever x 2 days – Vomiting x 1 day – Orange-sized swelling, left inguinal – Delirious What illnesses would you include in differential?
Plague Review Question Lesson 3, Question 2 What illnesses would you include in differential? A. B. C. D. Tularemia Chancroid Cat-Scratch Fever Bubonic Plague
Plague Review Question Lesson 3, Question 2 What illnesses would you include in differential? D. Bubonic Plague
Plague Review Question Lesson 3, Question 3 • • • 56 yo, M, Miami, Florida Salesman Hx of Travel to New Mexico last week No hx of animal exposure Symptoms – Malaise, myalgia, chills, headache, GI sxs x 3 days – Worsening sx’s, severe abdominal, productive cough, shortness of breath x 1 day – Today – Pupura, DIC, hypotension How would you relate it to plague?
Plague Review Question Lesson 3, Question 3 How would you relate it to plague? A. B. C. D. Presence of gram-positive bacteria Hx of travel to plague endemic area Rapid progression of disease B and C
Plague Review Question Lesson 3, Question 3 How would you relate it to plague? D. Both B and C Hx of travel to plague endemic area Rapid progression of disease
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