II. History
- First Plague Pandemic (Europe and Mediterranean, series of Plagues 541–767)
- Black Death (Europe, 1346 to 1353, start of the second Plague pandemic)
- https://en.wikipedia.org/wiki/Black_Death
- Killed 20 to 50 million europeans (up to 50% of europe population)
- Spread from Asia and Crimea to Europe via rat infested ships
- Third Plague pandemic (China and India, 1855–1960)
- Recent Plague Outbreaks
- Madagascar (fall 2017)
- Cases: 1800 as of November 2017
- Deaths: 127 as of November 2017
- U.S. (2015)
- Cases: 11 with 3 deaths
- Desert Southwest (Arizona, New Mexico) and Yosemite National Park
- Kwit (2015) MMWR Morb Mortal Wkly 64(33): 618-9 [PubMed]
- Madagascar (fall 2017)
III. Pathophysiology
- Bacteria: Yersinia pestis
-
Gram Negative Rod (some characterize as coccobacillus)
- Bipolar staining
- Facultative anaerobic bacterium
- Incubation
- Pneumonic Plague: 2-3 up to 6 days
- Bubonic Plague: 2-10 days
- Organism survival
- Viability
- Water, moist meal, grain for weeks
- Near freezing Temperatures from months to years
- Dry Sputum, flea feces, buried bodies
- Killed by
- Heated for 15 minutes at 72 C
- Several hours in direct sunlight
- Viability
- Transmission
- Reservoir: Rodents (rats, mice, ground squirrels)
- Arthropod Bites (e.g. Flea Bites) transmit bubonic form
- Aerosolized organisms transmit pneumonic form (e.g. Bioterrorism, person-to-person transmission)
- Infective Dose: 100 to 500 organisms need be inhaled for infection (moderately infective)
- Highly contagious in later stages of Pneumonic Plague with productive, purulent cough
- Keep infected patients under strict droplet precautions until 48 hours after Antibiotics started
IV. Types: Plague
- Bubonic Plague (80-95% of cases)
- Non-fluctuant inguinal Lymphadenitis
- Follows bite of an infected flea
- Primary septicemic Plague (10-20% of cases)
- May complicate Bubonic Plague or Pneumonic Plague
- Hematologic spread to other tissues and may result in lung involvement as well (Pneumonic Plague)
- Gastrointestinal symptoms predominate early
- Multiorgan failure, DIC, Sepsis occur later
- Pneumonic Plague (rare)
- Hematogenous seeding or droplet inhalation (highly contagious)
- Occurs from person-to-person transmission (or aeroslized Biological Weapon)
- Mortality >60% with treatment (approaches 100% without treatment)
V. Findings: Symptoms and signs
- Pneumonic Plague
- High fever
- Chills
- Headache
- Productive cough with Hemoptysis
- Toxic appearance
- Rapidly fulminant Pneumonia within 2-3 days of exposure
- Disseminated Intravascular Coagulation (DIC) or Shock may ensue
- Bubonic Plague
- Malaise
- High fever
- Tender, swollen Lymph Nodes (buboes)
- Primarily inguinal (legs most commonly flea bitten)
- Nodes swell and may become hemorrhagic and necrotic
- Septicemic Plague
- Abdominal Pain
- Subcutaneous Hemorrhage
- Disseminated Intravascular Coagulation
- Digital necrosis
VI. Labs
- Fluid Gram Stain and culture (from Sputum, tracheal aspirates, blood or aspirated buboe)
- Yersinia pestis Antigen detection or PCR
- Gram Negative Bacilli with "safety pin" appearance
- Organism grows on standard culture medium
VII. Imaging: Pneumonic Plague
-
Chest XRay
- Rapidly progresses from segmental to lobar consolidative Pneumonia, then multilobar and bilateral
VIII. Management
- Treat for 10-14 days
-
Contact Isolation
- Strict Droplet Isolation for plague Pneumonia patients for first 48 hours after Antibiotics started
- Healthcare staff should wear surgical masks (N95 Masks if performing aerosolizing procedures)
- Keep patient in private room, but negative airflow room is NOT needed
- Preferred Regimens (choose one)
- Streptomycin
- Adults and Children: 15 mg/kg (up to 1 to 2 g) IV/IM every 12 hours
- Gentamicin
- Adult: 5 mg/kg IM or IV every 24 hours
- Child: 2.5 mg/kg IM or IV every 8 hours
- Streptomycin
- Other Regimens (choose one)
- Doxycycline (over age 8 years)
- Convert to oral dosing when clinically improved
- Adult: 200 mg IV, then 100 mg IV every 12 hours
- Child: 2.2 mg/kg IV (max: 100 mg) every 12 hours
- Dose as adult for children over 45 kg
- Ciprofloxacin
- Adult: 400 mg IV every 12 hours
- When improved convert to 750 mg orally twice daily
- Child: 15 mg/kg (max: 400 mg) IV every 12 hours
- Adult: 400 mg IV every 12 hours
- Chloramphenicol
- Adult: 1 g IV every 6 hours
- Child: 25 mg/kg (max: 1 g) IV every 6 hours
- Doxycycline (over age 8 years)
IX. Prevention
- Eliminate infected vectors (fleas, rodents)
- Exposure to sunlight kills Y. pestis within hours
- However Y. pestis is viable in soil or grain for several weeks
-
Licensed, killed Vaccine (no longer available)
- Doses at 0, 1-3 months, and 5-6 months
- Booster at 6 month intervals x3, then every 1-2 years
- Effective against bubonic, but not pulmonic Plague
-
Post-exposure Prophylaxis (adult dosing below)
- Continue for 7 days or length of exposure
- Doxycycline 100 mg PO bid
- Ciprofloxacin 500 mg PO bid
- Tetracycline 500 mg PO qid
X. Prognosis
- Pneumonic Plague Mortality 100% if untreated (or treatment delayed >24 to 48 hours)
XI. References
- Charbonnet and Mace (2023) Crit Dec Emerg Med 37(4): 4-10
- Gilbert (2019) Sanford Guide, accessed 1/27/2020 on IOS version
- Seeyave (2015) Crit Dec Emerg Med 29(5): 13-21
- Inglesby (2000) JAMA 283:2281-90 [PubMed]
- Rathjen (2021) Am Fam Physician 104(4): 376-85 [PubMed]
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Related Studies
Definition (CHV) | an infectious disease |
Definition (CHV) | an infectious disease |
Definition (CHV) | an infectious disease |
Definition (CHV) | an infectious disease |
Definition (MEDLINEPLUS) |
Plague is an infection caused by the bacterium Yersinia pestis. The bacteria are found mainly in rats and in the fleas that feed on them. People and other animals can get plague from rat or flea bites. In the past, plague destroyed entire civilizations. Today plague is uncommon, due to better living conditions and antibiotics. There are three forms of plague:
Lab tests can diagnose plague. Treatment is a strong antibiotic. There is no vaccine. NIH: National Institute of Allergy and Infectious Diseases |
Definition (NCI) | A Gram-negative bacterial infection caused by Yersinia pestis. It is usually transmitted to humans from bites of infected rodent fleas. It is manifested as a bubonic, septicemic, or pneumonic plague. In bubonic plague, the lymph nodes adjacent to the site of the skin bite are infected and enlarged. In septicemic plague, the infection spreads directly through the bloodstream. In pneumonic plague, the infection spreads to the lungs either following bubonic plague, or by inhalation of infective droplets. If untreated, it may lead to death. |
Definition (MSH) | An acute infectious disease caused by YERSINIA PESTIS that affects humans, wild rodents, and their ectoparasites. This condition persists due to its firm entrenchment in sylvatic rodent-flea ecosystems throughout the world. Bubonic plague is the most common form. |
Definition (CSP) | acute infectious disease caused by Yersinia pestis that affects humans, wild rodents, and their ectoparasites; bubonic plague is the most common form. |
Concepts | Disease or Syndrome (T047) |
MSH | D010930 |
ICD9 | 020.9, 020 |
ICD10 | A20 , A20.9 |
SnomedCT | 187298009, 186290009, 58750007 |
LNC | LA10495-2 |
English | Yersinia pestis disease, Plague unspecified, Plague, unspecified, Yersinia pestis plague (diagnosis), Yersinia pestis plague, plague, plague (diagnosis), Yersinia pestis infection, Unspecified plague, Plague NOS, Plague [Disease/Finding], pest, pestilential fever, plagues, Plague unspecified (disorder), Infection by Yersinia pestis, Pest, Pestilential fever, Plague (disorder), Pasteurella; infection, pestis, Yersinia pestis; infection, infection; Pasteurella, pestis, infection; Yersinia pestis, Plague, NOS, Plague |
Dutch | pest, niet-gespecificeerd, Yersinia pestis-infectie, niet-gespecificeerde pest, Pasteurella; infectie, pestis, Yersinia pestis; infectie, infectie; Pasteurella, pestis, infectie; Yersinia pestis, Pest, niet gespecificeerd, pest, Bubonenpest, Pest |
French | Infection à Yersinia pestis, Peste, non précisée, Peste non précisée, Peste |
German | Pest, unspezifisch, Yersinia pestis-Infektion, unspezifische Pest, Pest, nicht naeher bezeichnet, Pest |
Italian | Infezione da Yersinia pestis, Peste non specificata, Peste |
Portuguese | Peste NE, Infecção por Yersinia pestis, Peste |
Spanish | Infección por Yersinia pestis, Peste no especificada, peste no especificada (trastorno), peste no especificada, Plague unspecified, infección por Yersinia pestis, peste (trastorno), peste, Peste |
Japanese | 詳細不明のペスト, ペスト菌感染, ペスト、詳細不明, ペスト, ペストショウサイフメイ, ショウサイフメイノペスト, ペストキンカンセン, 腺ペスト, 黒死病, 黒死症, ペスト |
Swedish | Pest |
Czech | mor, Infekce Yersinia pestis, Blíže neurčený mor, Mor, Mor, blíže neurčený |
Finnish | Rutto |
Russian | CHUMA, ЧУМА |
Korean | 페스트, 상세불명의 페스트 |
Polish | Dżuma, Zakażenie Yersinia pestis |
Hungarian | Pestis, nem meghatározott, Nem meghatározott pestis, Yersinia pestis fertőzés, pestis |
Norwegian | Pest |
Ontology: Yersinia pestis (C0043408)
Definition (NCI) | A species of facultatively anaerobic, Gram negative, rod shaped bacteria in the phylum Proteobacteria. This species is motile, positive for coagulase and fibrinolysin and negative for urease, indole, ornithine decarboxylase, oxidase, and pyrazinamidase. Some strains are able to ferment melibiose but none can metabolize sorbose, rhamnose, cellobiose, sucrose, or sorbitol. Y. pestis is found in rodents and fleas and is a pathogen that can cause pneumonic, septicemic and bubonic plague types in humans. |
Definition (NCI_CDISC) | Any bacterial organism that can be assigned to the species Yersinia pestis. |
Definition (CSP) | etiologic agent of plague in humans, rats, ground squirrels, and other rodents. |
Definition (MSH) | The etiologic agent of PLAGUE in man, rats, ground squirrels, and other rodents. |
Concepts | Bacterium (T007) |
MSH | D015010 |
SnomedCT | 54365000 |
LNC | LP30923-4, MTHU015543 |
English | Pasteurella pestis, Yersinia pestis, Yersinia pseudotubercul pestis, Y. pestis, Yersinia pseudotuberculosis subsp. pestis (Lehmann and Neumann 1896) Bercovier et al. 1981, Yersinia pestis (Lehmann and Neumann 1896) van Loghem 1944 (Approved Lists 1980), nom. cons, yersinia pestis, pestis y, y. pestis, pasteurella pestis, pestis yersinia, Bacillus pestis, Bacterium pestis, Pestisella pestis, Yersinia pseudotuberculosis subsp. pestis, YERSINIA PESTIS, PASTEURELLA PESTIS, Yersinia pseudotuberculosis subsp pestis, Yersinia pestis (organism) |
Swedish | Yersinia pestis |
Czech | Yersinia pestis, Pasteurella pestis |
Finnish | Yersinia pestis |
Russian | CHUMNAIA PALOCHKA, CHUMY VOZBUDITEL', ЧУМНАЯ ПАЛОЧКА, ЧУМЫ ВОЗБУДИТЕЛЬ |
Italian | Pasteurella pestis, Yersinia pestis |
Polish | Yersinia pestis, Pałeczki dżumy |
Japanese | エルシア・ペスティス, ペスト菌, エルシニアペスチス, パスツレラペスチス |
Norwegian | Pasteurella pestis, Yersinia pestis |
Spanish | Yersinia pestis (organismo), Yersinia pseudotuberculosis subespecie pestis, Yersinia pestis, Pasteurella pestis |
French | Pasteurella pestis, Yersinia pestis |
German | Pasteurella pestis, Yersinia pestis |
Dutch | Pasteurella pestis, Yersinia pestis |
Portuguese | Pasteurella pestis, Yersinia pestis |
Ontology: Bubonic Plague (C0282312)
Concepts | Disease or Syndrome (T047) |
MSH | D010930 |
ICD9 | 020.0 |
ICD10 | A20.0 |
SnomedCT | 50797007, 58750007 |
English | Plague, Bubonic, BUBONIC PLAGUE, black death, bubonic plague, bubonic plague (diagnosis), Bubonic Plague, black deaths, black plague, Black plague, Bubonic plague, Black death, Bubonic plague (disorder), bubonic; plague, plague; bubonic |
Dutch | zwarte pest, bubonen; pest, pest; bubonen, builenpest, Builenpest |
French | Peste noire, Peste bubonique |
German | schwarzer Tod, Bubonenpest, Beulenpest |
Portuguese | Peste negra, Peste Bubônica, Peste bubónica |
Spanish | Peste negra, Peste Bubónica, peste bubónica (trastorno), peste bubónica, peste fulminante, peste glandular, peste mayor, Peste bubónica |
Japanese | 腺ペスト, 黒死病, センペスト, コクシビョウ |
Italian | Peste bubbonica |
Czech | Bubonický mor, Černý mor, bubonický mor, dýmějový mor |
Korean | 림프절형 페스트 |
Hungarian | bubopestis, Fekete pestis |
Norwegian | Bubonpest, Byllepest |
Ontology: Pneumonic Plague (C0524688)
Concepts | Disease or Syndrome (T047) |
MSH | D010930 |
ICD9 | 020.5 |
ICD10 | A20.2 |
SnomedCT | 186283004, 38976008 |
English | Pneumonic plague, unspecified, PLAGUE PNEUMONIA, Plague, Pneumonic, Plagues, Pneumonic, Pneumonic Plagues, pneumonic plague (diagnosis), pneumonic plague, Pneumonic, unspecified plague, Pneumonic plague NOS, plague pneumonic, Pneumonic plague, unspecified (disorder), Pneumonic plague, Pneumonic plague (disorder), Yersinia pestis; pneumonia, lung; plague, plague; lung, plague; pneumonica, plague; pulmonary, pneumonia; Yersinia pestis, pulmonary; plague, Pneumonic plague, NOS, Pneumonic Plague, pneumonic; plague |
Italian | Peste polmonare, Peste polmonare non specificata, Peste pneumonica |
Dutch | pneumonische pest, niet-gespecificeerd, pneumonie, niet-gespecificeerde plaag, Yersinia pestis; pneumonie, long; pest, pest; long, pest; pneumonica, pest; pulmonaal, pneumonie; Yersinia pestis, pulmonaal; pest, Pneumonische vorm van pest, pneumonische pest, pneumonica; pest, Longpest |
French | Peste pneumonique, non précisée, Peste pneumonique, Peste pulmonaire |
German | Lungenpest, unspezifisch, Lunge, unspezifische Pest, Lungenpest |
Portuguese | Peste pneumónica NE, Peste Pneumônica, Peste pneumónica |
Spanish | Peste neumónica no especificada, Peste Neumónica, neumonía por peste, no especificada, neumonía por peste, no especificada (trastorno), neumonía pestosa, no especificada (trastorno), neumonía pestosa, no especificada, peste neumónica (trastorno), peste neumónica, Peste neumónica |
Japanese | 肺ペスト、詳細不明, 肺ペスト, ハイペストショウサイフメイ, ハイペスト |
Czech | Plicní mor, Plicní blíže neurčený mor, Plicní mor, blíže neurčený, plicní mor, pneumonický mor |
Korean | 폐렴형 페스트 |
Hungarian | tüdőpestis, tüdőpestis, nem meghatározott, Pneumoniás, nem meghatározott pestis |
Norwegian | Pneumonisk pest |