Yersinia pestis

Aka: Yersinia pestis, Pneumonic Plague, Bubonic Plague, Plague

1. See Also
   1. Bioterrorism
   2. Lymphadenitis
2. Epidemiology
   1. Madagascar (fall 2017)
      1. Cases: 1800 as of November 2017
      2. Deaths: 127 as of November 2017
      3. http://www.who.int/csr/disease/plague/en
   2. U.S. (2015)
      1. Cases: 11 with 3 deaths
      2. Desert Southwest (Arizona, New Mexico) and Yosemite National Park
      3. Kwit (2015) MMWR Morb Mortal Wkly 64(33): 618-9 [PubMed]
3. Pathophysiology
   1. Bacteria: Yersinia pestis
   2. Gram Negative Rod
      1. Bipolar staining
      2. Facultative anaerobic bacterium
   3. Incubation
      1. Pneumonic Plague: 2-3 days
      2. Bubonic Plague: 2-10 days
   4. Organism survival
      1. Viability
         1. Water, moist meal, grain for weeks
         2. Near freezing Temperatures from months to years
         3. Dry Sputum, flea feces, buried bodies
      2. Killed by
         1. Heated for 15 minutes at 72 C
         2. Several hours in direct sunlight
   5. Transmission
      1. Reservoir: Rodents (rats, mice, ground squirrels)
      2. Flea Bites transmit bubonic form
      3. Aerosolized organisms transmit pneumonic form (e.g. Bioterrorism, person-to-person transmission)
4. Types: Plague
   1. Bubonic Plague (80-95% of cases)
      1. Non-fluctuant inguinal Lymphadenitis
      2. Follows bite of an infected flea
   2. Primary septicemic Plague (10-20% of cases)
      1. May occur in combination with Bubonic Plague
      2. Gastrointestinal symptoms predominate early
      3. Multiorgan failure, DIC, Sepsis occur later
   3. Pneumonic Plague (rare)
      1. Hematogenous seeding or droplet inhalation (highly contagious)
      2. Occurs from person-to-person transmission (or aeroslized Biological Weapon)
      3. Mortality >60% with treatment (approaches 100% without treatment)
5. Findings: Symptoms and signs
   1. Pneumonic Plague
      1. High fever
      2. Chills
      3. Headache
      4. Productive cough with Hemoptysis
      5. Toxic appearance
      6. Rapidly fulminant Pneumonia within 2-3 days of exposure
      7. Disseminated Intravascular Coagulation (DIC) or Shock may ensue
   2. Bubonic Plague
      1. Malaise
      2. High fever
      3. Tender, swollen Lymph Nodes (buboes)
         1. Primarily inguinal (legs most commonly flea bitten)
6. Labs
   1. Fluid Gram Stain and culture (from Sputum, tracheal aspirates, blood or aspirated buboe)
      1. Yersinia pestis Antigen detection or PCR
      2. Gram Negative Bacilli with "safety pin" appearance
      3. Organism grows on standard culture medium
7. Imaging: Pneumonic Plague
   1. Chest XRay with consolidative Pneumonia, bilateral and multilobar
8. Management
   1. Treat for 10-14 days
   2. Contact Isolation
      1. Droplet Isolation for plague Pneumonia patients for first 48 hours
   3. Preferred Regimens (choose one)
      1. Streptomycin
         1. Adults and Children: 15 mg/kg (up to 2 g) IV/IM every 12 hours
      2. Gentamicin
         1. Adult: 5 mg/kg IM or IV every 24 hours
         2. Child: 2.5 mg/kg IM or IV every 8 hours
   4. Other Regimens (choose one)
      1. Doxycycline (over age 8 years)
         1. Convert to oral dosing when clinically improved
         2. Adult: 200 mg IV, then 100 mg IV every 12 hours
         3. Child: 2.2 mg/kg IV (max: 100 mg) every 12 hours
            1. Dose as adult for children over 45 kg
      2. Ciprofloxacin
         1. Adult: 400 mg IV every 12 hours
            1. When improved convert to 750 mg oral twice daily
         2. Child: 15 mg/kg (max: 400 mg) IV every 12 hours
      3. Chloramphenicol
         1. Adult: 1 g IV every 6 hours
         2. Child: 25 mg/kg (max: 1 g) IV every 6 hours
9. Prevention
   1. Licensed, killed Vaccine (no longer available)
      1. Doses at 0, 1-3 months, and 5-6 months
      2. Booster at 6 month intervals x3, then every 1-2 years
      3. Effective against bubonic, but not pulmonic Plague
   2. Post-exposure Prophylaxis (adult dosing below)
      1. Continue for 7 days or length of exposure
      2. Doxycycline 100 mg PO bid
      3. Ciprofloxacin 500 mg PO bid
      4. Tetracycline 500 mg PO qid
10. Prognosis
    1. Mortality 100% if untreated (or treatment delayed >48 hours)
11. References
    1. Gilbert (2019) Sanford Guide, accessed 1/27/2020 on IOS version
    2. Seeyave (2015) Crit Dec Emerg Med 29(5): 13-21
    3. Inglesby (2000) JAMA 283:2281-90 [PubMed]
    4. Rathjen (2021) Am Fam Physician 104(4): 376-85 [PubMed]